Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 177
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
2320 LINEVILLE RD, GREEN BAY, WI 54313-8836
(920) 434-5846
Mailing address
2320 LINEVILLE RD, GREEN BAY, WI 54313-8836
(920) 434-5846
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
8798042
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
36224100
—
WI
01
—
5130430
NCPDP
—
Enumeration date
12/10/2007
Last updated
10/28/2013
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