Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

Legal business name

SHOPKO STORES OPERATING CO LLC

Practice address

2015 S Defiance St
Archbold, OH 43502-9111

Phone

(419) 445-0052

Fax

(419) 445-0053

NPI assigned

May 17, 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 Bettiga, RPH

Title

Executive Vice President & Coo

Phone

(920) 429-4297

Specialties & licenses 3

Addresses

Other identifiers 2

Other names 1

• Shopko Pharmacy 654 Doing business as

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

{
    "created_epoch": "1147824000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1350864000000",
    "number": "1396797403",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2015 S DEFIANCE ST",
            "city": "ARCHBOLD",
            "state": "OH",
            "postal_code": "435029111",
            "telephone_number": "419-445-0052",
            "fax_number": "419-445-0053"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2015 S DEFIANCE ST",
            "city": "ARCHBOLD",
            "state": "OH",
            "postal_code": "435029111",
            "telephone_number": "419-445-0052",
            "fax_number": "419-445-0053"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-17",
        "last_updated": "2012-10-22",
        "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_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": "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": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "3668069",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2183551",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shopko Pharmacy 654",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Cathy Selgo
• Lexie Semer, M.S., CCC-SLP
• Shalom Ministries
• Casey Sharp
• Richard A Sherman, IMFT
• Jacquelyn Gayle Short, O.D.
• Andrew Shoup, ASSISTANT PT
• Shelley Simon-Miller
• Lindsay Christine Smallman, LSW
• Rachel Renae Smith, LSW

• Community/Retail Pharmacy in Archbold, OH
• Providers in Archbold, OH by specialty
• Community/Retail Pharmacy in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 22, 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.