Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 058
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
1755 N HUMISTON AVE, WORTHINGTON, MN 56187-1757
(507) 376-9309
(507) 372-7840
Mailing address
1755 N HUMISTON AVE, WORTHINGTON, MN 56187-1757
(507) 376-9309
(507) 372-7840
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
3336C0003X
Community/Retail Pharmacy
Primary
2628040
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0509463
—
IA
05
—
060258200
—
MN
05
—
0722512
—
IA
05
—
166523500
—
MN
01
—
2416801
NCPDP NUMBER
—
05
—
788690100
—
MN
Enumeration date
05/19/2006
Last updated
01/21/2014
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