Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

054015896 Issued in IL

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

ShopKo Pharmacy 150

Practice address

3030 Wabash Ave
Springfield, IL 62704-6413

Phone

(217) 698-9614

Fax

(217) 546-1761

NPI assigned

Jun 23, 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 2

Addresses

Other identifiers 2

Other names 1

• ShopKo Pharmacy 150 Doing business as

Locations

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

{
    "created_epoch": "1151020800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1218672000000",
    "number": "1790711737",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3030 WABASH AVE",
            "city": "SPRINGFIELD",
            "state": "IL",
            "postal_code": "627046413",
            "telephone_number": "217-698-9614",
            "fax_number": "217-546-1761"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3030 WABASH AVE",
            "city": "SPRINGFIELD",
            "state": "IL",
            "postal_code": "627046413",
            "telephone_number": "217-698-9614",
            "fax_number": "217-546-1761"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-23",
        "last_updated": "2008-08-14",
        "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": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "IL",
            "license": "054015896",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "371110040150",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "1468708",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 150",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Peter Shih
• Sang H Shin, MD
• Akhil Shivaprasad, MD
• Kavya Shivaram, MD
• Jacob Bayley Sholl, PA-C
• Shopko Stores Operating Co. LLC
• Shopko Stores Operating Co. LLC
• Kelcy S Short, LCPC
• Michael Short, PHARM.D., BCPS
• Stephanie Short, MD

• Community/Retail Pharmacy in Springfield, IL
• Providers in Springfield, IL by specialty
• Community/Retail Pharmacy in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 14, 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.