Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 503
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
1011 N WISCONSIN ST, PORT WASHINGTON, WI 53074-1207
(262) 284-3436
(262) 284-3422
Mailing address
1011 N WISCONSIN ST, PORT WASHINGTON, WI 53074-1207
(262) 284-3436
(262) 284-3422
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
8611042
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
33277300
—
WI
01
—
5128017
NCPDP
—
Enumeration date
05/24/2006
Last updated
08/15/2008
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