Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 608
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
1010 W RYAN ST, BRILLION, WI 54110-1079
(920) 429-4243
(920) 756-9262
Mailing address
1010 W RYAN ST, BRILLION, WI 54110-0000
(920) 756-2640
(920) 756-9262
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1922386275
—
WI
Enumeration date
08/03/2011
Last updated
02/08/2012
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