Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 091
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
1341 N MAIN ST, LOGAN, UT 84341-2221
(435) 753-2700
(435) 753-3894
Mailing address
1341 N MAIN ST, LOGAN, UT 84341-2221
(435) 753-2700
(435) 753-3894
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
333600000X
Pharmacy
1318501703
UT
3336C0003X
Community/Retail Pharmacy
Primary
1318501703
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
410985054604
—
UT
01
—
4606894
NCPDP NUMBER
—
05
—
804040900
—
ID
05
—
8533280
—
SD
05
—
PH246UT
—
AK
Enumeration date
05/13/2006
Last updated
06/06/2014
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