Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

Legal business name

SHOPKO STORES OPERATING CO LLC

Practice address

1150 E 3Rd St
Superior, NE 68978-2026

Phone

(402) 879-4811

Fax

(402) 879-4812

NPI assigned

May 19, 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 Bettiga, RPH

Title

Executive Vice President & Coo

Phone

(920) 429-4297

Specialties & licenses 3

Addresses

Other identifiers 6

Other names 1

• Shopko Pharmacy 692 Doing business as

Locations

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

{
    "created_epoch": "1147996800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1360627200000",
    "number": "1154374940",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 6",
            "city": "SUPERIOR",
            "state": "NE",
            "postal_code": "689780006",
            "telephone_number": "402-879-4811",
            "fax_number": "402-879-4812"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1150 E 3RD ST",
            "city": "SUPERIOR",
            "state": "NE",
            "postal_code": "689782026",
            "telephone_number": "402-879-4811",
            "fax_number": "402-879-4812"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-19",
        "last_updated": "2013-02-12",
        "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": "10025416000",
            "state": "NE"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100459130A",
            "state": "KS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10024985900",
            "state": "NE"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200389320E",
            "state": "KS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200389320F",
            "state": "KS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP",
            "identifier": "2816570",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shopko Pharmacy 692",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Cai Powell
• June L Pumphrey, PTA
• Traci Roth
• Alexis Schneider, M.S., CCC-SLP
• Jessica Shepler
• Shannon Short, PHARMD, BCPS
• Brooke Luella Slangal
• Stacy Lynne Souerdyke, PHARM D
• South Central Behavioral Services
• Jett Stenson, M.S., CCC-SLP

• All providers in Superior, NE
• Community/Retail Pharmacy in Nebraska

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 12, 2013; 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.