Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 615
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
291 S MAIN ST, CLINTONVILLE, WI 54929-1604
(715) 823-2350
(715) 823-2541
Mailing address
291 S MAIN ST, CLINTONVILLE, WI 54929-1604
(715) 823-2350
(715) 823-2541
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
—
33268600
—
WI
01
—
5127267
NCPDP NUMBER
—
Enumeration date
05/20/2006
Last updated
09/24/2012
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