# SHOPKO STORES OPERATING CO LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Shopko Pharmacy 631
- **Organization subpart:** No

## Provider details

- **NPI number:** 1144274812
- **Authorized official:** MR. MICHAEL BETTIGA RPH (EXECUTIVE VICE PRESIDENT & COO)
- **Authorized official phone:** (920) 429-4297

## Contact information

- **Practice address:** 1800 LAKE SHORE DR E, ASHLAND, WI 54806-2268
- **Practice address phone:** (715) 682-8306
- **Practice address fax:** (715) 682-4004
- **Mailing address:** 1800 LAKE SHORE DR E, ASHLAND, WI 54806-2268
- **Mailing address phone:** (715) 682-8306
- **Mailing address fax:** (715) 682-4004

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | — |
| 333600000X | Pharmacy | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | — | NULL | Yes |

## Other

- **Enumeration date:** 05/19/2006
- **Last updated:** 09/04/2012

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0459230072 | MEDICARE ID - TYPE UNSPECIFIED | — |