# SHOPKO STORES OPERATING CO LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** ShopKo Pharmacy 504
- **Organization subpart:** No

## Provider details

- **NPI number:** 1760665160
- **Authorized official:** MICHAEL BETTIGA RPH (SR. VICE PRESIDENT HEALTH SERVICES)
- **Authorized official phone:** (920) 429-4297

## Contact information

- **Practice address:** W3208 VAN ROY RD, APPLETON, WI 54915
- **Practice address phone:** (920) 111-1111
- **Mailing address:** W3208 VAN ROY RD, APPLETON, WI 54915

## Taxonomy

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

## Other

- **Enumeration date:** 12/10/2007
- **Last updated:** 08/15/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 36227000 | — | WI |