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 607

Practice address

1010 S Mainline Dr
Seymour, WI 54165-1150

Phone

(920) 833-0430

Fax

(920) 833-7556

NPI assigned

Oct 20, 2010

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

Executive Vice President and Coo

Phone

(920) 429-4297

Specialties & licenses 4

Addresses

Other identifiers 1

Other names 1

• ShopKo Pharmacy 607 Doing business as

Locations

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

{
    "created_epoch": "1287532800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1323388800000",
    "number": "1790095099",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1010 S MAINLINE DR",
            "city": "SEYMOUR",
            "state": "WI",
            "postal_code": "541651150",
            "telephone_number": "920-883-0430",
            "fax_number": "920-883-7556"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1010 S MAINLINE DR",
            "city": "SEYMOUR",
            "state": "WI",
            "postal_code": "541651150",
            "telephone_number": "920-833-0430",
            "fax_number": "920-833-7556"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-10-20",
        "last_updated": "2011-12-09",
        "status": "A",
        "authorized_official_last_name": "BETTIGA",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_title_or_position": "EXECUTIVE VICE PRESIDENT AND COO",
        "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": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1790095099",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 607",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Lynn M Rettler, REGISTERED NURSE
• Tim Schellinger, RPH
• Seymour Chiropractic SC
• Seymour Community School District
• Shopko Stores Operating Co LLC (ShopKo Optical 607)
• Tracy Sippl, M.S., CCC-SLP
• Wade David Skogman, D.C.,C.S.C.S.,D.A.B.
• St Vincent Hospital-Hospital Sisters-Third Order of St Francis (Prevea Health-Seymour DME Supplier)
• Laura Swett, N.P.
• Amber Thompson, RN, MSN

• Community/Retail Pharmacy in Seymour, WI
• Providers in Seymour, 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 Dec 9, 2011; 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.