Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

2041CP Issued in ID

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

ShopKo Pharmacy 095

Practice address

2655 Broadway Ave
Boise, ID 83706-4721

Phone

(208) 345-8728

Fax

(208) 343-6591

NPI assigned

Jun 1, 2006

Last updated

Jul 25, 2014By 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 4

Addresses

Other identifiers 2

Other names 1

• ShopKo Pharmacy 095 Doing business as

Locations

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

{
    "created_epoch": "1149120000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1406246400000",
    "number": "1326085077",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2655 BROADWAY AVE",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837064721",
            "telephone_number": "208-345-8728",
            "fax_number": "208-343-6591"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2655 BROADWAY AVE",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837064721",
            "telephone_number": "208-345-8728",
            "fax_number": "208-343-6591"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-01",
        "last_updated": "2014-07-25",
        "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": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "ID",
            "license": "2041CP",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "ID",
            "license": "2041CP",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000123000",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "1305108",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 095",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Krystal Shockey, PHARMD, BCIDP
• Laura S Shockley, M.A.
• Nicholas Shoebridge, D.O.
• Whitney Leigh Shofner Michalsky, M.D
• Shopko Stores Operating Co LLC (ShopKo Pharmacy 065)
• Shopko Stores Operating Co. LLC (ShopKo Optical 095)
• Shopko Stores Operating Co. LLC (ShopKo Optical 065)
• Brandon Shores, MS
• Jacquelyn Donna Shotwell-Vanderhoof
• Shaheed S Shoulars

• Community/Retail Pharmacy in Boise, ID
• Providers in Boise, 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 25, 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.