# SHOPKO STORES OPERATING CO LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** ShopKo Pharmacy 178
- **Organization subpart:** No

## Provider details

- **NPI number:** 1982865945
- **Authorized official:** MR. MICHAEL BETTIGA RPH (SR VICE PRESIDENT HEALTH SERVICES)
- **Authorized official phone:** (920) 429-4297

## Contact information

- **Practice address:** N 66 W 25201, CTH V V, SUSSEX, WI 53089
- **Practice address phone:** (262) 820-2611
- **Practice address fax:** (262) 820-2592
- **Mailing address:** N66 W 25201 CTH V V, SUSSEX, WI 53089

## 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 | — | NULL | Yes |

## Other

- **Enumeration date:** 06/23/2008
- **Last updated:** 07/25/2014

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 36229200 | — | WI |
| 01 | — | 488000297 | MEDCO | — |
| 01 | — | 5131014 | NCPDP \# | — |