Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 072
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
2120 THAIN GRADE, LEWISTON, ID 83501-4105
(208) 746-1044
(208) 746-0744
Mailing address
2120 THAIN GRADE, LEWISTON, ID 83501-4105
(208) 746-1044
(208) 746-0744
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
333600000X
Pharmacy
2036CP
ID
3336C0003X
Community/Retail Pharmacy
Primary
2036CP
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000311600
—
ID
01
—
0004888
WA LABOR & INDUSTRY
—
01
—
0215803
WA LABOR & INDUSTRY
—
01
—
1304651
NCPDP NUMBER
—
05
—
806730900
—
ID
Enumeration date
05/23/2006
Last updated
06/06/2014
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