Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 119
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
1350 N GALENA AVE, DIXON, IL 61021-1010
(815) 284-4127
(815) 284-6094
Mailing address
1350 N GALENA AVE, DIXON, IL 61021-1010
(815) 284-4127
(815) 284-6094
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
05401587
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1463809
NCPDP NUMBER
—
05
—
410985054001
—
IL
Enumeration date
06/23/2006
Last updated
08/14/2008
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