Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 068
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
800 E 17TH ST, IDAHO FALLS, ID 83404-6151
(208) 522-3572
(208) 522-3066
Mailing address
800 E 17TH ST, IDAHO FALLS, ID 83404-6151
(208) 522-3572
(208) 522-3066
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
333600000X
Pharmacy
2040CP
ID
3336C0003X
Community/Retail Pharmacy
Primary
2040CP
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000311500
—
ID
01
—
1304512
NCPDP NUMBER
—
Enumeration date
05/23/2006
Last updated
03/21/2014
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