# SHOPKO STORES OPERATING CO LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Other names:** ShopKo Pharmacy 050
- **Organization subpart:** No

## Provider details

- **NPI number:** 1871549220
- **Authorized official:** MR. MICHAEL J BETTIGA RPH (SR. VICE PRESIDENT HEALTH SERVICES)
- **Authorized official phone:** (920) 429-4297

## Contact information

- **Practice address:** 616 W JOHNSON ST, FOND DU LAC, WI 54935-3134
- **Practice address phone:** (920) 921-5490
- **Practice address fax:** (920) 921-7112
- **Mailing address:** 616 W JOHNSON ST, FOND DU LAC, WI 54935-3134
- **Mailing address phone:** (920) 921-5490
- **Mailing address fax:** (920) 921-7112

## 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 | 8612042 | WI | Yes |

## Other

- **Enumeration date:** 05/26/2006
- **Last updated:** 12/27/2013

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 33049600 | — | WI |
| 01 | — | 5117278 | NCPDP NUMBER | — |