Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 504
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL BETTIGA RPH (SR. VICE PRESIDENT HEALTH SERVICES)
(920) 429-4297
Entity
Organization
Contact information
Practice address
W3208 VAN ROY RD, APPLETON, WI 54915
(920) 111-1111
Mailing address
W3208 VAN ROY RD, APPLETON, WI 54915
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
—
36227000
—
WI
Enumeration date
12/10/2007
Last updated
08/15/2008
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