Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL BETTIGA (EXECUTIVE VP & COO)
(920) 429-4297
Entity
Organization
Contact information
Practice address
705 NORTHLAND DR, PRINCETON, MN 55371-2168
(763) 389-3111
(763) 389-1621
Mailing address
700 PILGRIM WAY, PO BOX 19060, GREEN BAY, WI 54304-5263
(920) 429-7137
(920) 429-4649
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
263663
MN
3336C0003X
Community/Retail Pharmacy
Primary
263663
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1376842286
—
MN
01
—
2430786
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
03/17/2011
Last updated
12/09/2011
Update your record
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