Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 718
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
671 WOLFORD AVE, LIBERTY, KY 42539
(606) 787-4236
(606) 787-4237
Mailing address
671 WOLFORD AVE, LIBERTY, KY 42539
(606) 787-4236
(606) 787-4237
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
—
1827584
NCPDP NUMBER
—
05
—
5401257000
—
KY
05
—
90006115
—
KY
Enumeration date
05/19/2006
Last updated
03/01/2013
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