Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

Legal business name

SHOPKO STORES OPERATING CO LLC

Practice address

5630 St Croix Trail
North Branch, MN 55056

Phone

(651) 674-9956

Fax

(651) 674-9907

NPI assigned

Jun 16, 2008

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

Sr. Vice President Health Services

Phone

(920) 429-4297

Specialties & licenses 4

Addresses

Other identifiers 2

Other names 1

• ShopKo Pharmacy 179 Doing business as

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

{
    "created_epoch": "1213574400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1406246400000",
    "number": "1811157662",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5630 ST CROIX TRAIL",
            "city": "NORTH BRANCH",
            "state": "MN",
            "postal_code": "55056",
            "telephone_number": "651-674-9956",
            "fax_number": "651-674-9907"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5630 ST CROIX TRAIL",
            "city": "NORTH BRANCH",
            "state": "MN",
            "postal_code": "55056",
            "telephone_number": "651-674-9956",
            "fax_number": "651-674-9907"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-06-16",
        "last_updated": "2014-07-25",
        "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_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": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP",
            "identifier": "2429226",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "387482100",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 179",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Amanda Sawyer, L.AC.
• Priya Devi Shaffer, DDS
• Shawn T McCullough DDS, PLLC
• Shift Solutions
• Shopko Stores Operating Co LLC
• Erica Sierra
• Amanda Marie Simonson, LADC
• Mike Singleton
• Lindsey Stormy-May Sitz, PHARMD
• Skelton Drug Inc

• Community/Retail Pharmacy in North Branch, MN
• Providers in North Branch, MN by specialty
• Community/Retail Pharmacy in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 25, 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.