Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 712
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MICHAEL BETTIGA RPH (EXCUTIVE VICE PRESIDENT & COO)
(920) 429-7297
Entity
Organization
Contact information
Practice address
502 E ROSS ST, PALMYRA, MO 63461-1739
(573) 769-1115
(573) 769-1116
Mailing address
502 E ROSS ST, PALMYRA, MO 63461-1739
(573) 769-1115
(573) 769-1116
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
—
2635223
NCPDP
—
Enumeration date
06/04/2006
Last updated
07/31/2012
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