Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

8605042 Issued in WI

Legal business name

SHOPKO STORES OPERATING CO LLC

Practice address

1771 Wisconsin Ave
Grafton, WI 53024-2437

Phone

(262) 375-0016

Fax

(262) 375-3519

NPI assigned

May 26, 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 4

Addresses

Other identifiers 2

Other names 1

• ShopKo Pharmacy 090 Doing business as

Locations

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

{
    "created_epoch": "1148601600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1402012800000",
    "number": "1740236199",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1771 WISCONSIN AVE",
            "city": "GRAFTON",
            "state": "WI",
            "postal_code": "530242437",
            "telephone_number": "262-375-0016",
            "fax_number": "262-375-3519"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1771 WISCONSIN AVE",
            "city": "GRAFTON",
            "state": "WI",
            "postal_code": "530242437",
            "telephone_number": "262-375-0016",
            "fax_number": "262-375-3519"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-26",
        "last_updated": "2014-06-06",
        "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": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "WI",
            "license": "8605042",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "33162200",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "5119450",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 090",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Lisa M Sershon, PA-C
• Rajeev K Seth, D.O.
• Sameer Sharma, MD
• Mark D Shewczyk, MD
• Christopher David Shoemaker, MED., NCC
• Shopko Stores Operating Co. LLC
• Shoptikal LLC
• Harjot Sidhu, MD
• Hector Sierra Escobedo, AA-C
• Kristina Suzanne Sikorski

• Community/Retail Pharmacy in Grafton, WI
• Providers in Grafton, 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 Jun 6, 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.