Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

8607042 Issued in WI

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

ShopKo Pharmacy 026

Practice address

2761 Prairie Ave
Beloit, WI 53511-2246

Phone

(608) 365-4418

Fax

(608) 365-2023

NPI assigned

May 26, 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 J Bettiga, RPH

Title

Sr. Vice President Health Services

Phone

(920) 429-4297

Specialties & licenses 4

Addresses

Other identifiers 3

Other names 1

• ShopKo Pharmacy 026 Doing business as

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

{
    "created_epoch": "1148601600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1400716800000",
    "number": "1265488613",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2761 PRAIRIE AVE",
            "city": "BELOIT",
            "state": "WI",
            "postal_code": "535112246",
            "telephone_number": "608-365-4418",
            "fax_number": "608-365-2023"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2761 PRAIRIE AVE",
            "city": "BELOIT",
            "state": "WI",
            "postal_code": "535112246",
            "telephone_number": "608-365-4418",
            "fax_number": "608-365-2023"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-26",
        "last_updated": "2014-05-22",
        "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": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "WI",
            "license": "8607042",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "5113460",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "410985054026",
            "state": "IL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "33006300",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 026",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Meshelle Lyniece Settles, RN
• Sylvia Maria Shamblin, R.N.
• Omer Sharif, M.D.
• Shayla D. Crays Smith, Aud, LTD
• Donna M. Sholts, LPN
• Shopko Stores Operating Co. LLC
• Shoptikal LLC
• Joshua Shucha, PT
• Stephanie Sisson
• Samantha Jo Skowronski, CD

• Community/Retail Pharmacy in Beloit, WI
• Providers in Beloit, 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 22, 2014; 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.