# SHOPKO STORES OPERATING CO LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** ShopKo Pharmacy 503
- **Organization subpart:** No

## Provider details

- **NPI number:** 1619922028
- **Authorized official:** MR. MICHAEL J BETTIGA RPH (SR. VICE PRESIDENT HEALTH SERVICES)
- **Authorized official phone:** (920) 429-4297

## Contact information

- **Practice address:** 1011 N WISCONSIN ST, PORT WASHINGTON, WI 53074-1207
- **Practice address phone:** (262) 284-3436
- **Practice address fax:** (262) 284-3422
- **Mailing address:** 1011 N WISCONSIN ST, PORT WASHINGTON, WI 53074-1207
- **Mailing address phone:** (262) 284-3436
- **Mailing address fax:** (262) 284-3422

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | — |
| 333600000X | Pharmacy | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | 8611042 | WI | Yes |

## Other

- **Enumeration date:** 05/24/2006
- **Last updated:** 08/15/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 33277300 | — | WI |
| 01 | — | 5128017 | NCPDP | — |