Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

9064-42 Issued in WI

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

ShopKo Pharmacy 604

Practice address

1011 E Spruce St
Abbotsford, WI 54405-9647

Phone

(715) 223-2480

Fax

(715) 223-2663

NPI assigned

Mar 17, 2011

Organization subpart

No

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

Authorized official

Name

Michael Bettiga, RPH

Title

Executive Vice President and Coo

Phone

(920) 429-4297

Specialties & licenses 3

Addresses

Other identifiers 1

Other names 1

• ShopKo Pharmacy 604 Doing business as

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

{
    "created_epoch": "1300320000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1306800000000",
    "number": "1144529058",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1011 E SPRUCE ST",
            "city": "ABBOTSFORD",
            "state": "WI",
            "postal_code": "544059647",
            "telephone_number": "715-223-2480",
            "fax_number": "715-223-2663"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1011 E SPRUCE ST",
            "city": "ABBOTSFORD",
            "state": "WI",
            "postal_code": "544059647",
            "telephone_number": "715-223-2480",
            "fax_number": "715-223-2663"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-03-17",
        "last_updated": "2011-05-31",
        "status": "A",
        "authorized_official_last_name": "BETTIGA",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_title_or_position": "EXECUTIVE VICE PRESIDENT AND COO",
        "authorized_official_telephone_number": "920-429-4297",
        "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": "9064-42",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1144529058",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 604",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Trista Holly Raycher, MS
• Christina H Rens, DDS
• Troy D Rens, DDS
• Kathryn Jennifer Schmidt
• School District of Abbotsford
• Lisa Louise Stariha, COTA
• Thompson Chiropractic & Wellness LLC
• Megan Thompson
• Ashley M Umlauft, PT
• Zena C Urbina, LPN

• Community/Retail Pharmacy in Abbotsford, WI
• Providers in Abbotsford, 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 May 31, 2011; 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.