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Organization
SHOPKO STORES OPERATING CO LLC
Active
Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 178
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MICHAEL BETTIGA RPH (SR VICE PRESIDENT HEALTH SERVICES)
(920) 429-4297
Entity
Organization
Contact information
Practice address
N 66 W 25201, CTH V V, SUSSEX, WI 53089
(262) 820-2611
(262) 820-2592
Mailing address
N66 W 25201 CTH V V, SUSSEX, WI 53089
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
NULL
332H00000X
Eyewear Supplier
—
NULL
333600000X
Pharmacy
—
NULL
3336C0003X
Community/Retail Pharmacy
Primary
—
NULL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
36229200
—
WI
01
—
488000297
MEDCO
—
01
—
5131014
NCPDP #
—
Enumeration date
06/23/2008
Last updated
07/25/2014
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