Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 064
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
2100 CALDWELL BLVD, NAMPA, ID 83651-1510
(208) 466-9616
(208) 463-1724
Mailing address
2100 CALDWELL BLVD, NAMPA, ID 83651-1510
(208) 466-9616
(208) 463-1724
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
333600000X
Pharmacy
2042CP
ID
3336C0003X
Community/Retail Pharmacy
Primary
2042CP
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000311800
—
ID
01
—
0193994
WA LABOR & INDUSTRY
—
01
—
0215801
WA LABOR & INDUSTRY
—
01
—
1304524
NCPDP NUMBER
—
Enumeration date
05/23/2006
Last updated
07/25/2014
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