Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

Legal business name

SHOPKO STORES OPERATING CO LLC

Practice address

N2585 Plaza Rd
Wautoma, WI 54982-7706

Phone

(920) 787-2090

Fax

(920) 787-4605

NPI assigned

May 19, 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 Bettiga, RPH

Title

Executive Vice President & Coo

Phone

(920) 429-4297

Specialties & licenses 3

Addresses

Other identifiers 1

Other names 1

• Shopko Pharmacy 617 Doing business as

Locations

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

{
    "created_epoch": "1147996800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1346716800000",
    "number": "1811941586",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "N2585 PLAZA RD",
            "city": "WAUTOMA",
            "state": "WI",
            "postal_code": "549827706",
            "telephone_number": "920-787-2090",
            "fax_number": "920-787-4605"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "N2585 PLAZA RD",
            "city": "WAUTOMA",
            "state": "WI",
            "postal_code": "549827706",
            "telephone_number": "920-787-2090",
            "fax_number": "920-787-4605"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-19",
        "last_updated": "2012-09-04",
        "status": "A",
        "authorized_official_last_name": "BETTIGA",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_title_or_position": "EXECUTIVE VICE PRESIDENT & 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": "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": "MEDICARE ID - TYPE UNSPECIFIED",
            "identifier": "0459230035",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shopko Pharmacy 617",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Amy Schoenoff, APNP
• Brian Schultz
• Megan Schwobe, APSW
• Susan Shemanski, CADC III
• Shopko Stores Operating Co LLC
• Shopko Stores Operating Co., LLC
• Kriste Simonson
• Renee L Soroko, MS, LPC
• Darren D Stelter
• The Pines Treatment & Recovery Center

• Community/Retail Pharmacy in Wautoma, WI
• Providers in Wautoma, 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 Sep 4, 2012; 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.