Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 028
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
800 E MAES AVE, KIMBERLY, WI 54136-1527
(920) 788-9154
(920) 788-3255
Mailing address
800 E MAES AVE, KIMBERLY, WI 54136-1527
(920) 788-9154
(920) 788-3255
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
8622042
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
33017200
—
WI
01
—
5114549
NCPDP NUMBER
—
Enumeration date
05/26/2006
Last updated
05/22/2014
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