# SHOPKO STORES OPERATING CO LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Shopko Pharmacy 617
- **Organization subpart:** No

## Provider details

- **NPI number:** 1811941586
- **Authorized official:** MR. MICHAEL BETTIGA RPH (EXECUTIVE VICE PRESIDENT & COO)
- **Authorized official phone:** (920) 429-4297

## Contact information

- **Practice address:** N2585 PLAZA RD, WAUTOMA, WI 54982-7706
- **Practice address phone:** (920) 787-2090
- **Practice address fax:** (920) 787-4605
- **Mailing address:** N2585 PLAZA RD, WAUTOMA, WI 54982-7706
- **Mailing address phone:** (920) 787-2090
- **Mailing address fax:** (920) 787-4605

## 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:** 05/19/2006
- **Last updated:** 09/04/2012

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0459230035 | MEDICARE ID - TYPE UNSPECIFIED | — |