Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 634
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
1020 W CHESTNUT ST, HOOPESTON, IL 60942-1967
(217) 283-4456
(217) 283-4634
Mailing address
PO BOX 1450, MINNEAPOLIS, MN 55485-5891
(217) 283-4456
(217) 283-4634
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
01
—
0459230130
MEDICARE ID - TYPE UNSPECIFIED
—
01
—
1477341
NCPDP
—
05
—
203606157004
—
IL
05
—
470626426119
—
IL
Enumeration date
07/01/2006
Last updated
08/30/2012
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