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 504

Practice address

W3208 Van Roy Rd
Appleton, WI 54915

Phone

(920) 111-1111

NPI assigned

Dec 10, 2007

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

Michael Bettiga, RPH

Title

Sr. Vice President Health Services

Phone

(920) 429-4297

Specialties & licenses 3

Addresses

Other identifiers 1

Other names 1

• ShopKo Pharmacy 504 Doing business as

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

{
    "created_epoch": "1197244800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1218758400000",
    "number": "1760665160",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "W3208 VAN ROY RD",
            "city": "APPLETON",
            "state": "WI",
            "postal_code": "54915"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "W3208 VAN ROY RD",
            "city": "APPLETON",
            "state": "WI",
            "postal_code": "54915",
            "telephone_number": "920-111-1111"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-12-10",
        "last_updated": "2008-08-15",
        "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_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": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "36227000",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 504",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Cheryl Lynn Shockey, R.D., M.S.
• Samantha Shoemaker, RN
• Shopko Institutional Care Services Co LLC (Shopko RxCare)
• Shopko Stores Operating Co LLC (ShopKo Optical 504)
• Shopko Stores Operating Co LLC (ShopKo Pharmacy 505)
• Shopko Stores Operating Co LLC (ShopKo Pharmacy 015)
• Shopko Stores Operating Co LLC (Shopko Eyecare Center 4505)
• Shopko Stores Operating Co. LLC (ShopKo Optical 015)
• Shoptikal LLC (Shopko Optical 4015)
• Shoptikal LLC (Shopko Optical 4033)

• Community/Retail Pharmacy in Appleton, WI
• Providers in Appleton, 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.