Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

Legal business name

SHOPKO STORES OPERATING CO LLC

Practice address

825 W Fulton St
Waupaca, WI 54981-1471

Phone

(715) 258-7621

Fax

(715) 258-6880

NPI assigned

Aug 17, 2012

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Michael Bettiga, RPH

Title

Executive Vice President & Coo

Phone

(920) 429-4297

Specialties & licenses 3

Addresses

Other identifiers 1

Other names 1

• Shopko Pharmacy 789 Doing business as

Locations

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

{
    "created_epoch": "1345161600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1354579200000",
    "number": "1265780464",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "825 W FULTON ST",
            "city": "WAUPACA",
            "state": "WI",
            "postal_code": "549811471"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "825 W FULTON ST",
            "city": "WAUPACA",
            "state": "WI",
            "postal_code": "549811471",
            "telephone_number": "715-258-7621",
            "fax_number": "715-258-6880"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-08-17",
        "last_updated": "2012-12-04",
        "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_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": "1265780464",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shopko Pharmacy 789",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Stacy Rae Schubert, OTR
• Heather Schultz, RN
• Robert William Sedlacek, M.D.
• Wendy Lynn Seegers
• Holly Marie Sherman, CNM
• Shopko Stores Operating Co LLC
• Shopko Stores Operating Co.,LLC
• Shoptikal LLC
• Debra Kay Skyrms, NCC LPC
• Ella Marie Slager, COTA

• All providers in Waupaca, WI
• Community/Retail Pharmacy in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 4, 2012; 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.