Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 630
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
1625 E BLASCHKO AVE, ARCADIA, WI 54612-1835
(608) 323-8134
(608) 323-8434
Mailing address
1625 E BLASCHKO AVE, ARCADIA, WI 54612-1835
(608) 323-8134
(608) 323-8434
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
—
0459230083
MEDICARE ID - TYPE UNSPECIFIED
—
Enumeration date
05/20/2006
Last updated
09/04/2012
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