Provider Demographics
NPI:1770893968
Name:SHOPKO INSTITUTIONAL CARE SERVICES CO LLC
Entity type:Organization
Organization Name:SHOPKO INSTITUTIONAL CARE SERVICES CO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT AND COO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BETTIGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-429-4297
Mailing Address - Street 1:2704 INDUSTRIAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53713-4806
Mailing Address - Country:US
Mailing Address - Phone:608-223-0054
Mailing Address - Fax:608-223-0225
Practice Address - Street 1:2704 INDUSTRIAL DRIVE
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53713-4806
Practice Address - Country:US
Practice Address - Phone:608-223-0054
Practice Address - Fax:608-223-0225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
WI90420423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1770893968Medicaid
IL203940171001Medicaid
6497850002Medicare NSC