Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 015
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
1000 W NORTHLAND AVE, APPLETON, WI 54914-1419
(920) 739-6871
(920) 731-6167
Mailing address
1000 W NORTHLAND AVE, APPLETON, WI 54914-1419
(920) 739-6871
(920) 731-6167
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
8592042
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
33129400
—
WI
01
—
5111290
NCPDP NUMBER
—
Enumeration date
05/26/2006
Last updated
01/21/2014
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