Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 761
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
205 BOYD AVE, NEWCASTLE, WY 82701-2965
(307) 746-2741
(307) 746-9405
Mailing address
205 BOYD AVE, NEWCASTLE, WY 82701-2965
(307) 746-2741
(307) 746-9405
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
—
102724700
—
WY
05
—
123288600
—
WY
05
—
123288601
—
WY
01
—
5202572
NCPDP
—
05
—
8530192
—
SD
Enumeration date
06/06/2006
Last updated
11/02/2012
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