# SHOPKO STORES OPERATING CO LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** ShopKo Pharmacy 604
- **Organization subpart:** No

## Provider details

- **NPI number:** 1144529058
- **Authorized official:** MICHAEL BETTIGA RPH (EXECUTIVE VICE PRESIDENT AND COO)
- **Authorized official phone:** (920) 429-4297

## Contact information

- **Practice address:** 1011 E SPRUCE ST, ABBOTSFORD, WI 54405-9647
- **Practice address phone:** (715) 223-2480
- **Practice address fax:** (715) 223-2663
- **Mailing address:** 1011 E SPRUCE ST, ABBOTSFORD, WI 54405-9647
- **Mailing address phone:** (715) 223-2480
- **Mailing address fax:** (715) 223-2663

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | — |
| 333600000X | Pharmacy | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | 9064-42 | WI | Yes |

## Other

- **Enumeration date:** 03/17/2011
- **Last updated:** 05/31/2011

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1144529058 | — | WI |