Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

8617042 Issued in WI

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

ShopKo Pharmacy 051

Practice address

1425 Janesville Ave
Fort Atkinson, WI 53538-2705

Phone

(920) 563-9351

Fax

(920) 563-7996

NPI assigned

May 26, 2006

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 2

Other names 1

• ShopKo Pharmacy 051 Doing business as

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

{
    "created_epoch": "1148601600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1218067200000",
    "number": "1124074570",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1425 JANESVILLE AVE",
            "city": "FORT ATKINSON",
            "state": "WI",
            "postal_code": "535382705",
            "telephone_number": "920-563-9351",
            "fax_number": "920-563-7996"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1425 JANESVILLE AVE",
            "city": "FORT ATKINSON",
            "state": "WI",
            "postal_code": "535382705",
            "telephone_number": "920-563-9351",
            "fax_number": "920-563-7996"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-26",
        "last_updated": "2008-08-07",
        "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": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "WI",
            "license": "8617042",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "5116985",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "33047200",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 051",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Matthew T Sdano, MD
• Stephen F Seaman, PHD
• Monica Sharma, MD
• Taylor R Shekey
• Emily Shepley, DPT
• Shopko Stores Operating Co. LLC (ShopKo Optical 051)
• Shoptikal LLC (Shopko Optical 4051)
• Showalter, Inc (Rock River Dental)
• Leslie Leigh Showalter, D.D.S.
• Robert P Sievert, D.O.

• Community/Retail Pharmacy in Fort Atkinson, WI
• Providers in Fort Atkinson, WI by specialty
• Community/Retail Pharmacy in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 7, 2008; 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.