NPIMap

Organization Active NPI

Shopko Stores Operating Co LLC

Doing business as ShopKo Express Pharmacy 502

  • Community/Retail Pharmacy
  • Green Bay, WI
National Provider Identifier
1831144070
Registry record updated May 22, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
8597042 Issued in WI
Legal business name
SHOPKO STORES OPERATING CO LLC
Doing business as
ShopKo Express Pharmacy 502
Practice address
2585 Lineville Rd
Green Bay, WI 54313-7122
Phone
(920) 662-9450
Fax
(920) 662-1912
NPI assigned
May 24, 2006
Last updated
May 22, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 22, 2014

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 4

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Eyewear Supplier 332H00000X
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X 8597042 WI Primary

Addresses

Primary practice location

2585 Lineville Rd
Green Bay, WI 54313-7122

Mailing address

2585 Lineville Rd
Green Bay, WI 54313-7122
Phone (920) 662-9450

Other identifiers 2

IdentifierTypeStateIssuer
5128168OtherNCPDP NUMBER
33279000MedicaidWI

Other names 1

  • ShopKo Express Pharmacy 502 Doing business as

National Provider Directory

National Provider Directory

NPI Registry JSON

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

{
    "created_epoch": "1148428800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1400716800000",
    "number": "1831144070",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2585 LINEVILLE RD",
            "city": "GREEN BAY",
            "state": "WI",
            "postal_code": "543137122",
            "telephone_number": "920-662-9450",
            "fax_number": "920-662-1912"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2585 LINEVILLE RD",
            "city": "GREEN BAY",
            "state": "WI",
            "postal_code": "543137122",
            "telephone_number": "920-662-9450",
            "fax_number": "920-662-1912"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-24",
        "last_updated": "2014-05-22",
        "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": "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": "WI",
            "license": "8597042",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "5128168",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "33279000",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Express Pharmacy 502",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Green Bay, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 22, 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.