NPIMap

Organization Active NPI

Shopko Stores Operating Co LLC

  • Community/Retail Pharmacy
  • Brigham City, UT
National Provider Identifier
1649221623
Registry record updated Aug 14, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
1323891703 Issued in UT
Legal business name
SHOPKO STORES OPERATING CO LLC
Doing business as
ShopKo Pharmacy 104
Practice address
747 S Main St
Brigham City, UT 84302-3359
Phone
(435) 723-1600
Fax
(435) 723-8213
NPI assigned
May 13, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 14, 2008

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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Community/Retail Pharmacy 3336C0003X 1323891703 UT Primary

Addresses

Primary practice location

747 S Main St
Brigham City, UT 84302-3359

Mailing address

747 S Main St
Brigham City, UT 84302-3359
Phone (435) 723-1600

Other identifiers 3

IdentifierTypeStateIssuer
804256000MedicaidID
4607163OtherNCPDP NUMBER
410985054179MedicaidUT

Other names 1

  • ShopKo Pharmacy 104 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": "1147478400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1218672000000",
    "number": "1649221623",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "747 S MAIN ST",
            "city": "BRIGHAM CITY",
            "state": "UT",
            "postal_code": "843023359",
            "telephone_number": "435-723-1600",
            "fax_number": "435-723-8213"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "747 S MAIN ST",
            "city": "BRIGHAM CITY",
            "state": "UT",
            "postal_code": "843023359",
            "telephone_number": "435-723-1600",
            "fax_number": "435-723-8213"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-13",
        "last_updated": "2008-08-14",
        "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": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "UT",
            "license": "1323891703",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "804256000",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "4607163",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "410985054179",
            "state": "UT"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 104",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Brigham City, UT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 14, 2008; 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.