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 718

Practice address

671 Wolford Ave
Liberty, KY 42539

Phone

(606) 787-4236

Fax

(606) 787-4237

NPI assigned

May 19, 2006

Last updated

Mar 1, 2013By 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 Bettiga, RPH

Title

Executive Vice President & Coo

Phone

(920) 429-4297

Specialties & licenses 3

Addresses

Other identifiers 3

Other names 1

• Shopko Pharmacy 718 Doing business as

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

• Shopko Stores Operating Co LLC

  dba Shopko Pharmacy 2651

  • Community/Retail Pharmacy
  • Hart, MI
  • NPI 1699727511

  Member Of

  NPD member

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

{
    "created_epoch": "1147996800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1362096000000",
    "number": "1508819384",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "671 WOLFORD AVE",
            "city": "LIBERTY",
            "state": "KY",
            "postal_code": "42539",
            "telephone_number": "606-787-4236",
            "fax_number": "606-787-4237"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "671 WOLFORD AVE",
            "city": "LIBERTY",
            "state": "KY",
            "postal_code": "42539",
            "telephone_number": "606-787-4236",
            "fax_number": "606-787-4237"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-19",
        "last_updated": "2013-03-01",
        "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": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5401257000",
            "state": "KY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "90006115",
            "state": "KY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "1827584",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shopko Pharmacy 718",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Mary Collene Rooks, LPCA
• Christine Nicole Rowland
• Mary Royse
• Laci Salyers
• Teresa Shofner, LPCA
• Hilary Ann Shuffett, P.A.
• Jennifer Shugars
• Stefanie Sidwell, DPT
• Michael S Sloane, PT
• Elissa Smith, OTR/L

• Community/Retail Pharmacy in Liberty, KY
• Providers in Liberty, KY by specialty
• Community/Retail Pharmacy in Kentucky

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 1, 2013; 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.