Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 089
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
1651 W ROSE ST, WALLA WALLA, WA 99362-1771
(509) 525-9207
(509) 529-7061
Mailing address
1651 W ROSE ST, WALLA WALLA, WA 99362-1771
(509) 525-9207
(509) 529-7061
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
3336C0003X
Community/Retail Pharmacy
Primary
CF00058648
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0006130033
—
WA
01
—
0050989
WA LABOR & INDUSTRY
—
01
—
0215798
WA LABOR & INDUSTRY
—
05
—
029348
—
OR
05
—
278351
—
OR
05
—
278381
—
OR
01
—
4919695
NCPDP NUMBER
—
Enumeration date
06/07/2006
Last updated
06/06/2014
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