Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 141
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
313 N ROOSEVELT AVE, BURLINGTON, IA 52601-1757
(319) 758-9526
(319) 753-2349
Mailing address
313 N ROOSEVELT AVE, BURLINGTON, IA 52601-1757
(319) 758-9526
(319) 753-2349
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
3336C0003X
Community/Retail Pharmacy
Primary
1039
IA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0438150
—
IA
05
—
0495143
—
IA
01
—
1619228
NCPDP NUMBER
—
05
—
371110040141
—
IL
Enumeration date
05/15/2006
Last updated
06/06/2014
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