Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 705
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MICHAEL BETTIGA RPH (EXECUTIVE VICE PRESIDENT & COO)
(920) 429-4297
Entity
Organization
Contact information
Practice address
2001 E 9TH ST, TRENTON, MO 64683-2599
(660) 359-2970
(660) 359-2979
Mailing address
2001 E 9TH ST, TRENTON, MO 64683-2599
(660) 359-2970
(660) 359-2979
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
2006008229
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2630918
NCPDP
—
01
—
5694490041
DME SUPPLIER
MO
Enumeration date
06/02/2006
Last updated
08/23/2012
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