Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

Shopko Pharmacy 776

Practice address

925 N 6TH Street
Greybull, WY 82426

Phone

(307) 765-4601

Fax

(307) 765-4600

NPI assigned

Sep 19, 2007

Organization subpart

No

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

Authorized official

Name

Mr. Michael Bettiga, RPH

Title

Executive Vice President & Coo

Phone

(920) 429-4297

Specialties & licenses 3

Addresses

Other identifiers 1

Other names 1

• Shopko Pharmacy 776 Doing business as

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

{
    "created_epoch": "1190160000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1350259200000",
    "number": "1114113511",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "925 N 6TH ST",
            "city": "GREYBULL",
            "state": "WY",
            "postal_code": "82426",
            "telephone_number": "307-765-4601",
            "fax_number": "307-765-4600"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "925 N 6TH STREET",
            "city": "GREYBULL",
            "state": "WY",
            "postal_code": "82426",
            "telephone_number": "307-765-4601",
            "fax_number": "307-765-4600"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-09-19",
        "last_updated": "2012-10-15",
        "status": "A",
        "authorized_official_last_name": "BETTIGA",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_title_or_position": "EXECUTIVE VICE PRESIDENT & COO",
        "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": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "125144900",
            "state": "WY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shopko Pharmacy 776",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Brett Jay Ohman, D.C.
• Randy E Waddell
• Samuel C Davidson DDS LLC
• Heather Sanford, LPC
• Jeffrey Lee Scott, D.O.
• Stephanie Kunkel Sloan
• Makyela Dawn Sorensen, PA-C
• Nickolas Shawn Sullivan-Kern
• Brandon Winters Tolman, PHARMD
• Julie C. Vanderploeg, L.P.C.

• Community/Retail Pharmacy in Greybull, WY
• Providers in Greybull, WY by specialty
• Community/Retail Pharmacy in Wyoming

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 15, 2012; 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.