Provider Demographics
NPI:1215981014
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:SR. VICE PRESIDENT HEALTH SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BETTIGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-429-4297
Mailing Address - Street 1:2510 S RESERVE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-7546
Mailing Address - Country:US
Mailing Address - Phone:406-721-3789
Mailing Address - Fax:406-721-3859
Practice Address - Street 1:2510 S RESERVE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7546
Practice Address - Country:US
Practice Address - Phone:406-721-3789
Practice Address - Fax:406-721-3859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MT11993336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0163513OtherWA LABOR & INDUSTRY
MT0212030Medicaid
MT5607355Medicaid
0215807OtherWA LABOR & INDUSTRY
MT0230469Medicaid
MT5607892Medicaid
2704408OtherNCPDP NUMBER
1111590016Medicare ID - Type Unspecified
5695760120Medicare NSC
0163513OtherWA LABOR & INDUSTRY
5695760120Medicare ID - Type Unspecified