Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 142
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
4810 AVENUE O, FORT MADISON, IA 52627-9677
(319) 372-8629
(319) 372-8698
Mailing address
4810 AVENUE O, FORT MADISON, IA 52627-9677
(319) 372-8629
(319) 372-8698
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
3336C0003X
Community/Retail Pharmacy
Primary
1040
IA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0154160255
—
MO
05
—
0438168
—
IA
05
—
0495093
—
IA
01
—
1619266
NCPDP NUMBER
—
05
—
371110040142
—
IL
Enumeration date
05/15/2006
Last updated
07/25/2014
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