Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 617
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
N2585 PLAZA RD, WAUTOMA, WI 54982-7706
(920) 787-2090
(920) 787-4605
Mailing address
N2585 PLAZA RD, WAUTOMA, WI 54982-7706
(920) 787-2090
(920) 787-4605
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
—
0459230035
MEDICARE ID - TYPE UNSPECIFIED
—
Enumeration date
05/19/2006
Last updated
09/04/2012
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