Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 645
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
3165 HOLTON WHITEHALL RD, WHITEHALL, MI 49461-9637
(231) 894-2635
(231) 893-4218
Mailing address
3165 HOLTON WHITEHALL RD, WHITEHALL, MI 49461-9637
(231) 894-2635
(231) 893-4218
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
—
2352754
NCPDP NUMBER
—
05
—
2352754
—
MI
05
—
3045810
—
MI
05
—
4819229
—
MI
05
—
4913820
—
MI
Enumeration date
05/17/2006
Last updated
10/09/2012
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