Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

2628024 Issued in MN

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

ShopKo Pharmacy 041

Practice address

1209 18TH Ave NW
Austin, MN 55912-1881

Phone

(507) 437-7616

Fax

(507) 437-8565

NPI assigned

May 19, 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 5

Other names 1

• ShopKo Pharmacy 041 Doing business as

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

{
    "created_epoch": "1147996800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1377561600000",
    "number": "1265486039",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1209 18TH AVE NW",
            "city": "AUSTIN",
            "state": "MN",
            "postal_code": "559121881",
            "telephone_number": "507-437-7616",
            "fax_number": "507-437-8565"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1209 18TH AVE NW",
            "city": "AUSTIN",
            "state": "MN",
            "postal_code": "559121881",
            "telephone_number": "507-437-7616",
            "fax_number": "507-437-8565"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-19",
        "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": null,
            "license": null,
            "primary": false
        },
        {
            "code": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MN",
            "license": "2628024",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "126023500",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "608057000",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "2416116",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "840020000",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0578674",
            "state": "IA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 041",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Community/Retail Pharmacy in Austin, MN
• Providers in Austin, MN by specialty
• Community/Retail Pharmacy in Minnesota

• 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.