# SHOPKO STORES OPERATING CO LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** ShopKo Pharmacy 086
- **Organization subpart:** No

## Provider details

- **NPI number:** 1437100518
- **Authorized official:** MR. MICHAEL J BETTIGA RPH (SR. VICE PRESIDENT HEALTH SERVICES)
- **Authorized official phone:** (920) 429-4297

## Contact information

- **Practice address:** 2266 N UNIVERSITY PKWY, PROVO, UT 84604-1510
- **Practice address phone:** (801) 375-2000
- **Practice address fax:** (801) 373-7179
- **Mailing address:** 2266 N UNIVERSITY PKWY, PROVO, UT 84604-1510
- **Mailing address phone:** (801) 375-2000
- **Mailing address fax:** (801) 373-7179

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | — |
| 332H00000X | Eyewear Supplier | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | 1313581703 | UT | Yes |

## Other

- **Enumeration date:** 05/13/2006
- **Last updated:** 05/22/2014

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 410985054067 | — | UT |
| 01 | — | 4606729 | NCPDP NUMBER | — |