Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 659
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
2410 DAHLKE AVE, AUBURN, NE 68305-3025
(402) 274-2434
(402) 274-2451
Mailing address
PO BOX 1450, MINNEAPOLIS, MN 55485-5891
(402) 274-2434
(402) 274-2451
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
—
0459230085
MEDICARE ID - TYPE UNSPECIFIED
—
05
—
10025417700
—
NE
01
—
2815958
NCPDP
—
05
—
47062642609
—
NE
Enumeration date
05/17/2006
Last updated
08/21/2012
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