Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 041
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
1209 18TH AVE NW, AUSTIN, MN 55912-1881
(507) 437-7616
(507) 437-8565
Mailing address
1209 18TH AVE NW, AUSTIN, MN 55912-1881
(507) 437-7616
(507) 437-8565
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
3336C0003X
Community/Retail Pharmacy
Primary
2628024
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0578674
—
IA
05
—
126023500
—
MN
01
—
2416116
NCPDP NUMBER
—
05
—
608057000
—
MN
05
—
840020000
—
MN
Enumeration date
05/19/2006
Last updated
08/27/2013
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