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Organization
SHOPKO STORES OPERATING CO LLC
Active
Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 140
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MICHAEL J BETTIGA RPH (SR. VICE PRESIDENT HEALTH SERVICES)
(920) 429-4297
Entity
Organization
Contact information
Practice address
1964 W MORTON AVE, JACKSONVILLE, IL 62650-2621
(217) 245-6259
(217) 243-9251
Mailing address
1964 W MORTON AVE, JACKSONVILLE, IL 62650-2621
(217) 245-6259
(217) 243-9251
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
NULL
332H00000X
Eyewear Supplier
—
NULL
3336C0003X
Community/Retail Pharmacy
Primary
054015893
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1468722
NCPDP NUMBER
—
05
—
371110040140
—
IL
Enumeration date
06/23/2006
Last updated
05/22/2014
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