# SHOPKO STORES OPERATING CO LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** ShopKo Pharmacy 054
- **Organization subpart:** No

## Provider details

- **NPI number:** 1962453845
- **Authorized official:** MR. MICHAEL J BETTIGA RPH (SR. VICE PRESIDENT HEALTH SERVICES)
- **Authorized official phone:** (920) 429-4297

## Contact information

- **Practice address:** 700 9TH AVE SE, WATERTOWN, SD 57201-5222
- **Practice address phone:** (605) 882-2011
- **Practice address fax:** (605) 886-6715
- **Mailing address:** 700 9TH AVE SE, WATERTOWN, SD 57201-5222
- **Mailing address phone:** (605) 882-2011
- **Mailing address fax:** (605) 886-6715

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | — |
| 332H00000X | Eyewear Supplier | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | 1001907 | SD | Yes |

## Other

- **Enumeration date:** 05/15/2006
- **Last updated:** 06/06/2014

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 260433000 | — | MN |
| 01 | — | 4303880 | NCPDP NUMBER | — |
| 05 | — | 8502830 | — | SD |
| 05 | — | 8502832 | — | SD |
| 05 | — | 9165520 | — | SD |
| 05 | — | 9165522 | — | SD |
| 05 | — | 979757200 | — | MN |