Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

2628040 Issued in MN

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

ShopKo Pharmacy 058

Practice address

1755 N Humiston Ave
Worthington, MN 56187-1757

Phone

(507) 376-9309

Fax

(507) 372-7840

NPI assigned

May 19, 2006

Last updated

Jan 21, 2014By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Michael J Bettiga, RPH

Title

Sr. Vice President Health Services

Phone

(920) 429-4297

Specialties & licenses 3

Addresses

Other identifiers 6

Other names 1

• ShopKo Pharmacy 058 Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147996800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1390262400000",
    "number": "1063466852",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1755 N HUMISTON AVE",
            "city": "WORTHINGTON",
            "state": "MN",
            "postal_code": "561871757",
            "telephone_number": "507-376-9309",
            "fax_number": "507-372-7840"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1755 N HUMISTON AVE",
            "city": "WORTHINGTON",
            "state": "MN",
            "postal_code": "561871757",
            "telephone_number": "507-376-9309",
            "fax_number": "507-372-7840"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-19",
        "last_updated": "2014-01-21",
        "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": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MN",
            "license": "2628040",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0509463",
            "state": "IA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0722512",
            "state": "IA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "060258200",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "166523500",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "2416801",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "788690100",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 058",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Jodi Lynn Scott, M.D.
• Kristine Ranae Shaffer, ARNP
• Keyurkumar Anilkumar Shah, M.D.
• Syed Asad Ali Shah, M.D.
• Meegan Shebeck, PT
• Shopko Stores Operating Co. LLC (ShopKo Optical 058)
• Stacy Wahl Slettum, FNP
• Katherine Elizabeth Smidt, CNM
• Grant R Sorensen, D.D.S.
• Maureen A Sorensen, D.D.S.

• Community/Retail Pharmacy in Worthington, MN
• Providers in Worthington, MN by specialty
• Community/Retail Pharmacy in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 21, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.