Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 788
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL BETTIGA RPH (EXECUTIVE VICE PRESIDENT & COO)
(920) 429-4297
Entity
Organization
Contact information
Practice address
200 COMMERCE DR, COLUMBUS, WI 53925-9567
(920) 623-2700
(920) 623-3749
Mailing address
200 COMMERCE DR, COLUMBUS, WI 53925-9567
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
05
—
1497003594
—
WI
Enumeration date
08/21/2012
Last updated
12/04/2012
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