Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 063
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
4215 YELLOWSTONE AVE, CHUBBUCK, ID 83202-2419
(208) 237-6828
(208) 238-8371
Mailing address
4215 YELLOWSTONE AVE, CHUBBUCK, ID 83202-2419
(208) 237-6828
(208) 238-8371
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
333600000X
Pharmacy
2039CP
ID
3336C0003X
Community/Retail Pharmacy
Primary
2039CP
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000123300
—
ID
01
—
1304550
NCPDP NUMBER
—
Enumeration date
06/01/2006
Last updated
06/06/2014
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