Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 670
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
615 DEARBORN ST, WAYNE, NE 68787-2244
(402) 375-2079
(402) 375-2082
Mailing address
615 DEARBORN ST, WAYNE, NE 68787-2244
(402) 375-2079
(402) 375-2082
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
05
—
0565648
—
IA
05
—
0721878
—
IA
05
—
10024985800
—
NE
05
—
10025416100
—
NE
01
—
2816582
NCPDP
—
Enumeration date
05/16/2006
Last updated
09/12/2012
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