Provider Demographics
NPI:1215108758
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 AND 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 1:718 4TH STREET
Mailing Address - Street 2:PO BOX 254
Mailing Address - City:GOTHENBURG
Mailing Address - State:NE
Mailing Address - Zip Code:69138
Mailing Address - Country:US
Mailing Address - Phone:308-537-8780
Mailing Address - Fax:308-537-4309
Practice Address - Street 1:718 4TH STREET
Practice Address - Street 2:
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138
Practice Address - Country:US
Practice Address - Phone:308-537-8780
Practice Address - Fax:308-537-4309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025618100Medicaid
5695760254Medicare NSC