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Organization
SHOPKO STORES OPERATING CO LLC
Active
Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 792
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL BETTIGA RPH (EXECUTIVE VICE PRESIDENT AND COO)
(920) 429-7297
Entity
Organization
Contact information
Practice address
79 HOMETOWN DRIVE, TOMAHAWK, WI 54487-9998
(715) 453-5996
Mailing address
79 HOMETOWN DRIVE, TOMAHAWK, WI 54487-9998
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
05
—
1265877435
—
WI
Enumeration date
05/01/2013
Last updated
11/18/2013
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