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 180

Practice address

3271 Marketplace Dr
Council Bluffs, IA 51501

Phone

(712) 366-0377

Fax

(712) 366-9020

NPI assigned

Jul 29, 2008

Last updated

May 13, 2009By 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

Sr. Vice President Health Services

Phone

(920) 429-4297

Specialties & licenses 2

Addresses

Other identifiers 4

Other names 1

• ShopKo Pharmacy 180 Doing business as

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

{
    "created_epoch": "1217289600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1242172800000",
    "number": "1700042884",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3271 MARKETPLACE DR",
            "city": "COUNCIL BLUFFS",
            "state": "IA",
            "postal_code": "51501",
            "telephone_number": "712-366-0377",
            "fax_number": "712-366-9020"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3271 MARKETPLACE DR",
            "city": "COUNCIL BLUFFS",
            "state": "IA",
            "postal_code": "51501",
            "telephone_number": "712-366-0377",
            "fax_number": "712-366-9020"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-07-29",
        "last_updated": "2009-05-13",
        "status": "A",
        "authorized_official_last_name": "BETTIGA",
        "authorized_official_first_name": "MICHAEL",
        "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": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WELLMARK BCBS IA DME BLUE SHIELD ALLIANCE SELECT SELECT FIRST",
            "identifier": "1700042884",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10025730800",
            "state": "NE"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP",
            "identifier": "1623621",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1700042884",
            "state": "IA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 180",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Tara Rae Shew
• Anna Shields, PTA
• Augustine Thabo Shija
• William Meredith Shipley, PHARMD, RPH
• Shopko Stores Operating Co LLC (ShopKo Optical 180)
• Jacqueline Short
• Kara Shroll Blue, OTD, OTR/L
• Nathan Charles Shumway, D.P.M.
• Cindy Marie Shupe, MSN, FNP-C
• Casey Sicuso

• Community/Retail Pharmacy in Council Bluffs, IA
• Providers in Council Bluffs, 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 May 13, 2009; 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.