# SHOPKO STORES OPERATING CO LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Shopko Pharmacy 601
- **Organization subpart:** No

## Provider details

- **NPI number:** 1891014635
- **Authorized official:** MR. MICHAEL BETTIGA RPH (EXECUTIVE VICE PRESIDENT AND COO)
- **Authorized official phone:** (920) 429-4297

## Contact information

- **Practice address:** 802 N MAIN ST, KEWAUNEE, WI 54216-0274
- **Practice address phone:** (920) 388-2231
- **Practice address fax:** (920) 388-2459
- **Mailing address:** 802 N MAIN ST, PO BOX 274, KEWAUNEE, WI 54216-0274
- **Mailing address phone:** (920) 388-2231
- **Mailing address fax:** (920) 388-2459

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | — |
| 333600000X | Pharmacy | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | 9006-042 | WI | Yes |

## Other

- **Enumeration date:** 05/19/2010
- **Last updated:** 09/22/2010

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1891014635 | — | WI |