Provider Demographics
NPI:1699089995
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:
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 1:1345 S FREDERICK AVE
Mailing Address - Street 2:
Mailing Address - City:OELWEIN
Mailing Address - State:IA
Mailing Address - Zip Code:50662-3060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1345 S FREDERICK AVE
Practice Address - Street 2:
Practice Address - City:OELWEIN
Practice Address - State:IA
Practice Address - Zip Code:50662-3060
Practice Address - Country:US
Practice Address - Phone:319-283-2028
Practice Address - Fax:319-283-6653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-29
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA332B00000X
333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5695760238Medicare NSC