# SHOPKO STORES OPERATING CO LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** ShopKo Pharmacy 033
- **Organization subpart:** No

## Provider details

- **NPI number:** 1508812959
- **Authorized official:** MR. MICHAEL J BETTIGA RPH (SR. VICE PRESIDENT HEALTH SERVICES)
- **Authorized official phone:** (920) 429-4297

## Contact information

- **Practice address:** 1578 APPLETON RD, MENASHA, WI 54952-1104
- **Practice address phone:** (920) 722-1895
- **Practice address fax:** (920) 722-3195
- **Mailing address:** 1578 APPLETON RD, MENASHA, WI 54952-1104
- **Mailing address phone:** (920) 722-1895
- **Mailing address fax:** (920) 722-3195

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | — |
| 332H00000X | Eyewear Supplier | — | NULL | — |
| 333600000X | Pharmacy | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | 8628042 | WI | Yes |

## Other

- **Enumeration date:** 05/26/2006
- **Last updated:** 04/16/2014

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 33031600 | — | WI |
| 01 | — | 5115779 | NCPDP NUMBER | — |