Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 742
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MICHAEL BETTIGA RPH (EXECUTIVE VICE PRESIDENT & COO)
(920) 429-4297
Entity
Organization
Contact information
Practice address
421 GATEWAY DR NE, EAST GRAND FORKS, MN 56721-1619
(218) 773-0940
(218) 773-1049
Mailing address
421 GATEWAY DR NE, EAST GRAND FORKS, MN 56721-1619
(218) 773-0940
(218) 773-1049
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2419009
NCPDP
—
05
—
272498000
—
MN
05
—
775560100
—
MN
Enumeration date
05/18/2006
Last updated
10/09/2012
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