Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 067
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
1649 POLELINE RD E, TWIN FALLS, ID 83301-3592
(208) 734-3791
(208) 736-7476
Mailing address
1649 POLELINE RD E, TWIN FALLS, ID 83301-3592
(208) 734-3791
(208) 736-7476
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
2043CP
ID
3336C0003X
Community/Retail Pharmacy
Primary
2043CP
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000311700
—
ID
01
—
0183167
WA LABOR & INDUSTRY
—
01
—
0215808
WA LABOR & INDUSTRY
—
01
—
1304562
NCPDP NUMBER
—
Enumeration date
06/01/2006
Last updated
07/10/2009
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