Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 180
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MICHAEL BETTIGA RPH (SR. VICE PRESIDENT HEALTH SERVICES)
(920) 429-4297
Entity
Organization
Contact information
Practice address
3271 MARKETPLACE DR, COUNCIL BLUFFS, IA 51501
(712) 366-0377
(712) 366-9020
Mailing address
3271 MARKETPLACE DR, COUNCIL BLUFFS, IA 51501
(712) 366-0377
(712) 366-9020
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
10025730800
—
NE
01
—
1623621
NCPDP
—
01
—
1700042884
WELLMARK BCBS IA DME BLUE SHIELD ALLIANCE SELECT SELECT FIRST
—
05
—
1700042884
—
IA
Enumeration date
07/29/2008
Last updated
05/13/2009
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