Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

1320601703 Issued in UT

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

ShopKo Pharmacy 097

Practice address

4850 W 3500 S
West Valley City, UT 84120-2927

Phone

(801) 966-6500

Fax

(801) 966-8805

NPI assigned

May 13, 2006

Last updated

Aug 27, 2013By 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 2

Other names 1

• ShopKo Pharmacy 097 Doing business as

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

• Shopko Stores Operating Co LLC

  dba Shopko Pharmacy 2651

  • Community/Retail Pharmacy
  • Hart, MI
  • NPI 1699727511

  Member Of

  NPD member

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

{
    "created_epoch": "1147478400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1377561600000",
    "number": "1194776179",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4850 W 3500 S",
            "city": "WEST VALLEY CITY",
            "state": "UT",
            "postal_code": "841202927",
            "telephone_number": "801-966-6500",
            "fax_number": "801-966-8805"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4850 W 3500 S",
            "city": "WEST VALLEY CITY",
            "state": "UT",
            "postal_code": "841202927",
            "telephone_number": "801-966-6500",
            "fax_number": "801-966-8805"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-13",
        "last_updated": "2013-08-27",
        "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": "UT",
            "license": "1320601703",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "410985054151",
            "state": "UT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "4606945",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 097",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Antonio Shade, CSW
• Sudha B Shah, MD
• Mary E Shapiro, MD
• McKenzie A Shemwell, CSW
• Scott D Sheridan, MD
• Shopko Stores Operating Co. LLC (ShopKo Optical 097)
• Shoptikal LLC (Shopko Optical 4097)
• Hannah Shurtliff
• Mitzi Marie Siebert, NURSE PRACTITIONER
• Diana Alexandra Sierra

• Community/Retail Pharmacy in West Valley City, UT
• Providers in West Valley City, UT by specialty
• Community/Retail Pharmacy in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 27, 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.