Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 060
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
2610 BRIDGE AVE, ALBERT LEA, MN 56007-2075
(507) 373-9424
(507) 373-0977
Mailing address
2610 BRIDGE AVE, ALBERT LEA, MN 56007-2075
(507) 373-9424
(507) 373-0977
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
3336C0003X
Community/Retail Pharmacy
Primary
2628079
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0722504
—
IA
05
—
0985630
—
IA
01
—
2416786
NCPDP NUMBER
—
05
—
820058100
—
MN
05
—
827463000
—
MN
Enumeration date
05/19/2006
Last updated
07/25/2014
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