Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 086
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
2266 N UNIVERSITY PKWY, PROVO, UT 84604-1510
(801) 375-2000
(801) 373-7179
Mailing address
2266 N UNIVERSITY PKWY, PROVO, UT 84604-1510
(801) 375-2000
(801) 373-7179
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
3336C0003X
Community/Retail Pharmacy
Primary
1313581703
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
410985054067
—
UT
01
—
4606729
NCPDP NUMBER
—
Enumeration date
05/13/2006
Last updated
05/22/2014
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