Active NPI
Shopko Stores Operating Co LLC
- Community/Retail Pharmacy
- Salt Lake City, UT
National Provider Identifier
1306897384
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Community/Retail Pharmacy
- License
- 1332031703
- Legal business name
- SHOPKO STORES OPERATING CO LLC
- Doing business as
- ShopKo Pharmacy 110
- Practice address
- 2290 S 1300 E
Salt Lake City, UT 84106-2831 - Phone
- (801) 467-8900
- Fax
- (801) 467-8291
- NPI assigned
- May 13, 2006
- Organization subpart
- No
NPPES NPI Registry
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 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Durable Medical Equipment & Medical Supplies | 332B00000X | |||
| Community/Retail Pharmacy | 3336C0003X | 1332031703 | UT | Primary |
Addresses
Primary practice location
2290 S 1300 E
Salt Lake City, UT 84106-2831
Mailing address
2290 S 1300 E
Salt Lake City, UT 84106-2831
Phone (801) 467-8900
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 4607454 | Other | NCPDP NUMBER | |
| 410985054232 | Medicaid | UT |
Other names 1
- ShopKo Pharmacy 110
National Provider Directory
National Provider DirectoryNPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1147478400000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1218672000000",
"number": "1306897384",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2290 S 1300 E",
"city": "SALT LAKE CITY",
"state": "UT",
"postal_code": "841062831",
"telephone_number": "801-467-8900",
"fax_number": "801-467-8291"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2290 S 1300 E",
"city": "SALT LAKE CITY",
"state": "UT",
"postal_code": "841062831",
"telephone_number": "801-467-8900",
"fax_number": "801-467-8291"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "SHOPKO STORES OPERATING CO LLC",
"organizational_subpart": "NO",
"enumeration_date": "2006-05-13",
"last_updated": "2008-08-14",
"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": "3336C0003X",
"taxonomy_group": "",
"desc": "Pharmacy, Community/Retail Pharmacy",
"state": "UT",
"license": "1332031703",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NCPDP NUMBER",
"identifier": "4607454",
"state": null
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "410985054232",
"state": "UT"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "ShopKo Pharmacy 110",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Salt Lake City, UT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 14, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.