Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 510
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
800 RIVERSIDE DR, WAUPACA, WI 54981-1943
(715) 256-1115
(715) 256-1105
Mailing address
800 RIVERSIDE DR, WAUPACA, WI 54981-1943
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
—
1558618595
—
WI
Enumeration date
08/09/2012
Last updated
10/29/2012
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