Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 104
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
747 S MAIN ST, BRIGHAM CITY, UT 84302-3359
(435) 723-1600
(435) 723-8213
Mailing address
747 S MAIN ST, BRIGHAM CITY, UT 84302-3359
(435) 723-1600
(435) 723-8213
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
1323891703
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
410985054179
—
UT
01
—
4607163
NCPDP NUMBER
—
05
—
804256000
—
ID
Enumeration date
05/13/2006
Last updated
08/14/2008
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