Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 702
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
908 E 14TH ST., LARNED, KS 67550
(620) 285-3546
(620) 285-3898
Mailing address
PO BOX 1450, NW 5891, MINNEAPOLIS, MN 55485-1450
(620) 285-3546
(620) 285-3898
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
—
200389320M
—
KS
01
—
200389320N
KS DME
KS
Enumeration date
02/04/2008
Last updated
11/08/2012
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