NPIMap

Organization Active NPI

Shopko Stores Operating Co LLC

  • Community/Retail Pharmacy
  • Menasha, WI
National Provider Identifier
1508812959
Registry record updated Apr 16, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
8628042 Issued in WI
Legal business name
SHOPKO STORES OPERATING CO LLC
Practice address
1578 Appleton Rd
Menasha, WI 54952-1104
Phone
(920) 722-1895
Fax
(920) 722-3195
NPI assigned
May 26, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 16, 2014

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

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Eyewear Supplier 332H00000X
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X 8628042 WI Primary

Addresses

Primary practice location

1578 Appleton Rd
Menasha, WI 54952-1104

Mailing address

1578 Appleton Rd
Menasha, WI 54952-1104
Phone (920) 722-1895

Other identifiers 2

IdentifierTypeStateIssuer
33031600MedicaidWI
5115779OtherNCPDP NUMBER

Other names 1

  • ShopKo Pharmacy 033 Doing business as

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1148601600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1397606400000",
    "number": "1508812959",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1578 APPLETON RD",
            "city": "MENASHA",
            "state": "WI",
            "postal_code": "549521104",
            "telephone_number": "920-722-1895",
            "fax_number": "920-722-3195"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1578 APPLETON RD",
            "city": "MENASHA",
            "state": "WI",
            "postal_code": "549521104",
            "telephone_number": "920-722-1895",
            "fax_number": "920-722-3195"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-26",
        "last_updated": "2014-04-16",
        "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": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "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": "WI",
            "license": "8628042",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "33031600",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "5115779",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 033",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Menasha, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 16, 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.