Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 075
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
2510 S RESERVE ST, MISSOULA, MT 59801-7546
(406) 721-3789
(406) 721-3859
Mailing address
2510 S RESERVE ST, MISSOULA, MT 59801-7546
(406) 721-3789
(406) 721-3859
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
1199
MT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0163513
WA LABOR & INDUSTRY
—
05
—
0212030
—
MT
01
—
0215807
WA LABOR & INDUSTRY
—
05
—
0230469
—
MT
01
—
2704408
NCPDP NUMBER
—
05
—
5607355
—
MT
05
—
5607892
—
MT
Enumeration date
05/19/2006
Last updated
08/11/2009
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