Provider Demographics
NPI:1932153749
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 114
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE PRESIDENT HEALTH SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BETTIGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-429-4297
Mailing Address - Street 1:801 W CENTRAL ENTRANCE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-5468
Mailing Address - Country:US
Mailing Address - Phone:218-727-7139
Mailing Address - Fax:218-727-6240
Practice Address - Street 1:801 W CENTRAL ENTRANCE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-5468
Practice Address - Country:US
Practice Address - Phone:218-727-7139
Practice Address - Fax:218-727-6240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332H00000X, 333600000X
MN26280823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN022715300Medicaid
2421016OtherNCPDP NUMBER
MN561447000Medicaid
WI33194800Medicaid
MN375038800Medicaid
MN375038800Medicaid
MN561447000Medicaid