Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Pharmacy 174
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
2323 W PIONEER PKWY, PEORIA, IL 61615-1833
(309) 691-4682
(309) 691-4807
Mailing address
2323 W PIONEER PKWY, PEORIA, IL 61615-1833
(309) 691-4682
(309) 691-4807
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
—
—
3336C0003X
Community/Retail Pharmacy
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1473014
NCPDP NUMBER
—
05
—
410985054174
—
IL
Enumeration date
06/24/2006
Last updated
09/11/2025
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