Shopko Stores Operating Co LLC

Key facts

NPI

1023063294

Entity type

Organization (NPI type 2)

Primary specialty

Community/Retail Pharmacy 3336C0003X

License

8634042 (WI)

Legal business name

SHOPKO STORES OPERATING CO LLC

Practice address

1105 E Grand Ave
Rothschild, WI 54474-1024

Phone

(715) 359-4251

Fax

(715) 359-0145

NPI assigned

May 24, 2006

Organization subpart

No

Authorized official

Name

Mr. Michael J Bettiga, RPH

Title

Sr. Vice President Health Services

Phone

(920) 429-4297

National Provider Directory

Locations

Specialties & licenses

Addresses

Other identifiers

Other names

• ShopKo Pharmacy 008 Doing business as

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Jun 6, 2014.

{
    "created_epoch": "1148428800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1402012800000",
    "number": "1023063294",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1105 E GRAND AVE",
            "city": "ROTHSCHILD",
            "state": "WI",
            "postal_code": "544741024",
            "telephone_number": "715-359-4251",
            "fax_number": "715-359-0145"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1105 E GRAND AVE",
            "city": "ROTHSCHILD",
            "state": "WI",
            "postal_code": "544741024",
            "telephone_number": "715-359-4251",
            "fax_number": "715-359-0145"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-24",
        "last_updated": "2014-06-06",
        "status": "A",
        "authorized_official_last_name": "BETTIGA",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "SR. VICE PRESIDENT HEALTH SERVICES",
        "authorized_official_telephone_number": "920-429-4297",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "RPH"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "WI",
            "license": "8634042",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "5112913",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "33001000",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 008",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Shopko Stores Operating Co. LLC
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All providers in Rothschild, WI · Community/Retail Pharmacy in Wisconsin