Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

Shopko Pharmacy 612

Practice address

203 N Main St
Lake Mills, WI 53551-1610

Phone

(920) 648-3455

Fax

(920) 648-2712

NPI assigned

Jan 18, 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 and Coo

Phone

(920) 429-4297

Specialties & licenses 3

Addresses

Other identifiers 1

Other names 1

• SHOPKO PHARMACY 612 Doing business as

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

{
    "created_epoch": "1326844800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1334880000000",
    "number": "1407127889",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "203 N MAIN ST",
            "city": "LAKE MILLS",
            "state": "WI",
            "postal_code": "535511610",
            "telephone_number": "920-648-3455",
            "fax_number": "920-648-2712"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "203 N MAIN ST",
            "city": "LAKE MILLS",
            "state": "WI",
            "postal_code": "535511610",
            "telephone_number": "920-648-3455",
            "fax_number": "920-648-2712"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-01-18",
        "last_updated": "2012-04-20",
        "status": "A",
        "authorized_official_last_name": "BETTIGA",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_title_or_position": "EXECUTIVE VICE PRESIDENT AND 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": "1407127889",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SHOPKO PHARMACY 612",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Jeffrey James Salkowski, PT
• Michael Schilling
• Christina Marie Schopf
• Judith May Schwager, RN BSN
• Nancy Shea, LCSW
• Virginia Simon, MS, CCC-SLP
• Juliet Anne Slavens, D.D.S.
• Sharon Ann Smith
• Pamela Sue Speckbrock, OTR
• Ruthanne Reichert Taylor, FNP-BC

• Community/Retail Pharmacy in Lake Mills, WI
• Providers in Lake Mills, WI by specialty
• Community/Retail Pharmacy in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 20, 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.