Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

263662 Issued in MN

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

ShopKo Pharmacy 605

Practice address

340 Highway 65 S
Mora, MN 55051-1619

Phone

(320) 679-5950

Fax

(320) 679-5956

NPI assigned

Mar 17, 2011

Last updated

Mar 17, 2011By 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

Michael Bettiga, RPH

Title

Executive Vice President and Coo

Phone

(920) 429-4297

Specialties & licenses 3

Addresses

Other names 1

• ShopKo Pharmacy 605 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": "1300320000000",
    "number": "1568761484",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "340 HIGHWAY 65 S",
            "city": "MORA",
            "state": "MN",
            "postal_code": "550511619",
            "telephone_number": "320-679-5950",
            "fax_number": "320-679-5956"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "340 HIGHWAY 65 S",
            "city": "MORA",
            "state": "MN",
            "postal_code": "550511619",
            "telephone_number": "320-679-5950",
            "fax_number": "320-679-5956"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-03-17",
        "last_updated": "2011-03-17",
        "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": "MN",
            "license": "263662",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 605",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Mariette Sourial, PHARM.D.

• Community/Retail Pharmacy in Mora, MN
• Providers in Mora, 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 Mar 17, 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.