Provider Demographics
NPI:1316990716
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 1:819 11TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:WAUKON
Mailing Address - State:IA
Mailing Address - Zip Code:52172-7593
Mailing Address - Country:US
Mailing Address - Phone:563-568-3668
Mailing Address - Fax:563-568-3693
Practice Address - Street 1:819 11TH AVE SW
Practice Address - Street 2:
Practice Address - City:WAUKON
Practice Address - State:IA
Practice Address - Zip Code:52172-7593
Practice Address - Country:US
Practice Address - Phone:563-568-3668
Practice Address - Fax:563-568-3693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0495804Medicaid
IA0174805Medicaid
1619343OtherNCPDP
5695760235Medicare NSC