Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 671
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MICHAEL BETTIGA RPH (EXECUTIVE VICE PRESIDENT & COO)
(920) 429-4297
Entity
Organization
Contact information
Practice address
819 11TH AVE SW, WAUKON, IA 52172-7593
(563) 568-3668
(563) 568-3693
Mailing address
819 11TH AVE SW, WAUKON, IA 52172-7593
(563) 568-3668
(563) 568-3693
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0174805
—
IA
05
—
0495804
—
IA
01
—
1619343
NCPDP
—
Enumeration date
05/18/2006
Last updated
10/25/2012
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