Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 102
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
2741 ROOSEVELT RD, MARINETTE, WI 54143-3833
(715) 735-0325
(715) 735-0111
Mailing address
2741 ROOSEVELT RD, MARINETTE, WI 54143-3833
(715) 735-0325
(715) 735-0111
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
8600042
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2653481
—
MI
05
—
33171000
—
WI
05
—
4913409
—
MI
01
—
5120148
NCPDP NUMBER
—
05
—
5120148
—
MI
Enumeration date
05/26/2006
Last updated
06/06/2014
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