Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 003
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
3415 CALUMET AVE, MANITOWOC, WI 54220-5427
(920) 684-0251
(920) 684-7706
Mailing address
3415 CALUMET AVE, MANITOWOC, WI 54220-5427
(920) 684-0251
(920) 684-7706
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
8598042
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
33001100
—
WI
01
—
5112874
NCPDP NUMBER
—
Enumeration date
05/24/2006
Last updated
06/06/2014
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