Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 040
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MICAEL J BETTIGA RPH (SR. VICE PRESIDENT HEALTH SERVICES)
(920) 429-4297
Entity
Organization
Contact information
Practice address
3025 HAMILTON BLVD, SIOUX CITY, IA 51104-2407
(712) 255-8055
(712) 255-4784
Mailing address
3025 HAMILTON BLVD, SIOUX CITY, IA 51104-2407
(712) 255-8055
(712) 255-4784
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
3336C0003X
Community/Retail Pharmacy
Primary
514
IA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0208470
—
IA
05
—
0495028
—
IA
05
—
10025413500
—
NE
01
—
1613531
NCPDP NUMBER
—
05
—
41098505408
—
NE
05
—
8531560
—
SD
05
—
8531562
—
SD
05
—
9164712
—
SD
Enumeration date
05/15/2006
Last updated
06/06/2014
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