Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

8624042 Issued in WI

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

ShopKo Express Pharmacy 501

Practice address

3705 Monroe Rd
De Pere, WI 54115-4020

Phone

(920) 336-6096

Fax

(920) 338-8961

NPI assigned

May 26, 2006

Last updated

Aug 15, 2008By 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 J Bettiga, RPH

Title

Sr. Vice President Health Services

Phone

(920) 429-4297

Specialties & licenses 3

Addresses

Other identifiers 2

Other names 1

• ShopKo Express Pharmacy 501 Doing business as

Locations

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Jill Gostisha, PHARM.D

  • Pharmacist
  • De Pere, WI
  • NPI 1700291952
  NPD (past)
• Nicole L Hiltunen, RPH

  • Pharmacist
  • De Pere, WI
  • NPI 1114270113
  NPD (past)
• Justin Michael Mattern, PHARM.D.

  • Pharmacist
  • De Pere, WI
  • NPI 1538562293
  NPD (past)

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

{
    "created_epoch": "1148601600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1218758400000",
    "number": "1730135195",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3705 MONROE RD",
            "city": "DE PERE",
            "state": "WI",
            "postal_code": "541154020",
            "telephone_number": "920-336-6096",
            "fax_number": "920-338-8961"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3705 MONROE RD",
            "city": "DE PERE",
            "state": "WI",
            "postal_code": "541154020",
            "telephone_number": "920-336-6096",
            "fax_number": "920-338-8961"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-26",
        "last_updated": "2008-08-15",
        "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": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "WI",
            "license": "8624042",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "5128170",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "33278900",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Express Pharmacy 501",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Vijayalakshmi Shetty
• Shifting Healthcare, LLC
• Rachel N Shimek, MS, OTR
• Shopko Optical Manufacturing LLC
• Shopko Stores Operating Co LLC (ShopKo Pharmacy 005)
• Shopko Stores Operating Co. LLC (ShopKo Optical 005)
• Shoptikal LLC (Shopko Optical 4005)
• Gregory Vincent Signorelli
• Ann M Sislo
• Gabrielle Paige Siudzinski, APSW

• Community/Retail Pharmacy in De Pere, WI
• Providers in De Pere, WI by specialty
• Community/Retail Pharmacy in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 15, 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.