Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 635
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
251 S 4TH ST, SAVANNA, IL 61074-2123
(815) 273-3581
(815) 273-3591
Mailing address
251 S 4TH ST, SAVANNA, IL 61074-2123
(815) 273-3581
(815) 273-3591
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0459230056
MEDICARE ID - TYPE UNSPECIFIED
—
Enumeration date
07/01/2006
Last updated
09/07/2012
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