Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 026
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
2761 PRAIRIE AVE, BELOIT, WI 53511-2246
(608) 365-4418
(608) 365-2023
Mailing address
2761 PRAIRIE AVE, BELOIT, WI 53511-2246
(608) 365-4418
(608) 365-2023
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
8607042
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
33006300
—
WI
05
—
410985054026
—
IL
01
—
5113460
NCPDP NUMBER
—
Enumeration date
05/26/2006
Last updated
05/22/2014
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