Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 139
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
3200 BROADWAY ST, QUINCY, IL 62301-3712
(217) 224-0776
(217) 224-0890
Mailing address
3200 BROADWAY ST, QUINCY, IL 62301-3712
(217) 224-0776
(217) 224-0890
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
054015890
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1468683
NCPDP NUMBER
—
05
—
371110040139
—
IL
Enumeration date
06/23/2006
Last updated
08/14/2008
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