Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

1040 Issued in IA

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

ShopKo Pharmacy 142

Practice address

4810 Avenue O
Fort Madison, IA 52627-9677

Phone

(319) 372-8629

Fax

(319) 372-8698

NPI assigned

May 15, 2006

Organization subpart

No

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

Addresses

Other identifiers 5

Other names 1

• ShopKo Pharmacy 142 Doing business as

Member of 1

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

• Shopko Stores Operating Co LLC

  • Community/Retail Pharmacy
  • Afton, WY
  • NPI 1891971719

  Member Of

  NPD member

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

{
    "created_epoch": "1147651200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1406246400000",
    "number": "1699726588",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4810 AVENUE O",
            "city": "FORT MADISON",
            "state": "IA",
            "postal_code": "526279677",
            "telephone_number": "319-372-8629",
            "fax_number": "319-372-8698"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4810 AVENUE O",
            "city": "FORT MADISON",
            "state": "IA",
            "postal_code": "526279677",
            "telephone_number": "319-372-8629",
            "fax_number": "319-372-8698"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-15",
        "last_updated": "2014-07-25",
        "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": "IA",
            "license": "1040",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "1619266",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "371110040142",
            "state": "IL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0154160255",
            "state": "MO"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0438168",
            "state": "IA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0495093",
            "state": "IA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 142",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Mark A. Saathoff, D.P.M.
• Artemio Capili Santiago, MD
• John Danley Schroeder, D.D.S.
• Michelle D Scott, CNA
• Emma Kay Shipley, M.S. CCC-SLP
• Shopko Stores Operating Co. LLC
• Mariah Skelley, APRN CNP
• Carrie Skibba
• Carolyn Ruth Smith, O.D.
• Kristin C Smith, OT

• Community/Retail Pharmacy in Fort Madison, IA
• Providers in Fort Madison, IA by specialty
• Community/Retail Pharmacy in Iowa

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 25, 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.