Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

2038CP Issued in ID

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

ShopKo Pharmacy 169

Practice address

3499 E Fairview Ave
Meridian, ID 83642-5848

Phone

(208) 884-1286

Fax

(208) 884-1186

NPI assigned

Jun 1, 2006

Last updated

Jul 10, 2009By 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 169 Doing business as

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

{
    "created_epoch": "1149120000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1247184000000",
    "number": "1235176983",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3499 E FAIRVIEW AVE",
            "city": "MERIDIAN",
            "state": "ID",
            "postal_code": "836425848",
            "telephone_number": "208-884-1286",
            "fax_number": "208-884-1186"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3499 E FAIRVIEW AVE",
            "city": "MERIDIAN",
            "state": "ID",
            "postal_code": "836425848",
            "telephone_number": "208-884-1286",
            "fax_number": "208-884-1186"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-01",
        "last_updated": "2009-07-10",
        "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": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "ID",
            "license": "2038CP",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "ID",
            "license": "2038CP",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "1306807",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "805516800",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 169",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Jazzmine Shinn
• Andrew Lewis Jend Shirk, DPT
• Marissa Shirley, PHARMD
• Emily Shlodzik, MS
• Matthew Claibourne Shonnard, MD, MPH
• Shopko Stores Operating Co. LLC (ShopKo Optical 169)
• Tucker Short
• Alexander Shriver
• Laura Ann Shukla, P.T.
• Erin Marie Shumard

• Community/Retail Pharmacy in Meridian, ID
• Providers in Meridian, ID by specialty
• Community/Retail Pharmacy in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 10, 2009; 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.