Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

263663 Issued in MN

Legal business name

SHOPKO STORES OPERATING CO LLC

Practice address

705 Northland Dr
Princeton, MN 55371-2168

Phone

(763) 389-3111

Fax

(763) 389-1621

NPI assigned

Mar 17, 2011

Organization subpart

No

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

Authorized official

Name

Michael Bettiga

Title

Executive VP & Coo

Phone

(920) 429-4297

Specialties & licenses 3

Addresses

Other identifiers 2

Other names 1

• Shopko Pharmacy Doing business as

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

{
    "created_epoch": "1300320000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1323388800000",
    "number": "1376842286",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "700 PILGRIM WAY",
            "address_2": "PO BOX 19060",
            "city": "GREEN BAY",
            "state": "WI",
            "postal_code": "543045263",
            "telephone_number": "920-429-7137",
            "fax_number": "920-429-4649"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "705 NORTHLAND DR",
            "city": "PRINCETON",
            "state": "MN",
            "postal_code": "553712168",
            "telephone_number": "763-389-3111",
            "fax_number": "763-389-1621"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-03-17",
        "last_updated": "2011-12-09",
        "status": "A",
        "authorized_official_last_name": "BETTIGA",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_title_or_position": "EXECUTIVE VP & COO",
        "authorized_official_telephone_number": "920-429-4297"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "MN",
            "license": "263663",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MN",
            "license": "263663",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP PROVIDER IDENTIFICATION NUMBER",
            "identifier": "2430786",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1376842286",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shopko Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Andrew Setrum, AU.D.
• Cassandra Marie Shallenberger, RD, LD
• Nicole Sherven, PHARM D
• Juliann Hazelrigg Shobe, MS, RD, LD
• Samantha Shoop
• Shirley Singh
• Stephen George Snell, DDS
• Soaring Eagles Transportation, Inc.
• Daniel William Solbrack, O.D.
• Brenda Sommerdorf, MD

• Community/Retail Pharmacy in Princeton, MN
• Providers in Princeton, 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 Dec 9, 2011; 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.