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Organization
SHOPKO STORES OPERATING CO LLC
Active
Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 631
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MICHAEL BETTIGA RPH (EXECUTIVE VICE PRESIDENT & COO)
(920) 429-4297
Entity
Organization
Contact information
Practice address
1800 LAKE SHORE DR E, ASHLAND, WI 54806-2268
(715) 682-8306
(715) 682-4004
Mailing address
1800 LAKE SHORE DR E, ASHLAND, WI 54806-2268
(715) 682-8306
(715) 682-4004
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
NULL
333600000X
Pharmacy
—
NULL
3336C0003X
Community/Retail Pharmacy
Primary
—
NULL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0459230072
MEDICARE ID - TYPE UNSPECIFIED
—
Enumeration date
05/19/2006
Last updated
09/04/2012
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