# SHOPKO STORES OPERATING CO LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** ShopKo Pharmacy 091
- **Organization subpart:** No

## Provider details

- **NPI number:** 1750332730
- **Authorized official:** MR. MICHAEL J BETTIGA RPH (SR. VICE PRESIDENT HEALTH SERVICES)
- **Authorized official phone:** (920) 429-4297

## Contact information

- **Practice address:** 1341 N MAIN ST, LOGAN, UT 84341-2221
- **Practice address phone:** (435) 753-2700
- **Practice address fax:** (435) 753-3894
- **Mailing address:** 1341 N MAIN ST, LOGAN, UT 84341-2221
- **Mailing address phone:** (435) 753-2700
- **Mailing address fax:** (435) 753-3894

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | — |
| 332H00000X | Eyewear Supplier | — | NULL | — |
| 333600000X | Pharmacy | 1318501703 | UT | — |
| 3336C0003X | Community/Retail Pharmacy | 1318501703 | UT | Yes |

## Other

- **Enumeration date:** 05/13/2006
- **Last updated:** 06/06/2014

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 410985054604 | — | UT |
| 01 | — | 4606894 | NCPDP NUMBER | — |
| 05 | — | 804040900 | — | ID |
| 05 | — | 8533280 | — | SD |
| 05 | — | PH246UT | — | AK |