Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 059
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
1001 HIGHWAY 15 S, FAIRMONT, MN 56031-4456
(507) 238-9488
(507) 238-9038
Mailing address
1001 HIGHWAY 15 S, FAIRMONT, MN 56031-4456
(507) 238-9488
(507) 238-9038
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
3336C0003X
Community/Retail Pharmacy
Primary
2628053
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1972557767
—
IA
01
—
2416748
NCPDP NUMBER
—
05
—
662688200
—
MN
05
—
854687000
—
MN
05
—
969857400
—
MN
Enumeration date
05/19/2006
Last updated
06/11/2014
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