NPIMap

Organization Active NPI

Shopko Stores Operating Co LLC

  • Community/Retail Pharmacy
  • Saint Cloud, MN
National Provider Identifier
1609829464
Registry record updated May 22, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
2627960 Issued in MN
Legal business name
SHOPKO STORES OPERATING CO LLC
Practice address
4161 2ND St S
Saint Cloud, MN 56301-3761
Phone
(320) 253-3280
Fax
(320) 253-5790
NPI assigned
May 19, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 22, 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 3

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Eyewear Supplier 332H00000X
Community/Retail Pharmacy 3336C0003X 2627960 MN Primary

Addresses

Primary practice location

4161 2ND St S
Saint Cloud, MN 56301-3761

Mailing address

4161 2ND St S
Saint Cloud, MN 56301-3761
Phone (320) 253-3280

Other identifiers 5

IdentifierTypeStateIssuer
606234200MedicaidMN
625857300MedicaidMN
0154160058MedicaidMN
2414249OtherNCPDP NUMBER
578612000MedicaidMN

Other names 1

  • ShopKo Pharmacy 017 Doing business as

National Provider Directory

National Provider Directory

NPI Registry JSON

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

{
    "created_epoch": "1147996800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1400716800000",
    "number": "1609829464",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4161 2ND ST S",
            "city": "SAINT CLOUD",
            "state": "MN",
            "postal_code": "563013761",
            "telephone_number": "320-253-3280",
            "fax_number": "320-253-5790"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4161 2ND ST S",
            "city": "SAINT CLOUD",
            "state": "MN",
            "postal_code": "563013761",
            "telephone_number": "320-253-3280",
            "fax_number": "320-253-5790"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-19",
        "last_updated": "2014-05-22",
        "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": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MN",
            "license": "2627960",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "606234200",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "625857300",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0154160058",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "2414249",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "578612000",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 017",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Saint Cloud, MN

Sources for this page

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