Provider Demographics
NPI:1154374940
Name:SHOPKO STORES OPERATING CO LLC
Entity type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT & COO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BETTIGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-429-4297
Mailing Address - Street 1:PO BOX 6
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:NE
Mailing Address - Zip Code:68978-0006
Mailing Address - Country:US
Mailing Address - Phone:402-879-4811
Mailing Address - Fax:402-879-4812
Practice Address - Street 1:1150 E 3RD ST
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:NE
Practice Address - Zip Code:68978-2026
Practice Address - Country:US
Practice Address - Phone:402-879-4811
Practice Address - Fax:402-879-4812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025416000Medicaid
KS100459130AMedicaid
NE10024985900Medicaid
KS200389320EMedicaid
KS200389320FMedicaid
2816570OtherNCPDP
KS200389320FMedicaid
5694490023Medicare NSC