Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

Legal business name

SHOPKO STORES OPERATING CO LLC

Practice address

616 E US Highway 9
Forest City, IA 50436-1012

Phone

(641) 582-2780

Fax

(641) 582-5057

NPI assigned

May 18, 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 3

Other names 1

• Shopko Pharmacy 791 Doing business as

Locations

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

{
    "created_epoch": "1147910400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1350604800000",
    "number": "1851344352",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "616 E US HIGHWAY 9",
            "city": "FOREST CITY",
            "state": "IA",
            "postal_code": "504361012",
            "telephone_number": "641-582-2780",
            "fax_number": "641-582-5057"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "616 E US HIGHWAY 9",
            "city": "FOREST CITY",
            "state": "IA",
            "postal_code": "504361012",
            "telephone_number": "641-582-2780",
            "fax_number": "641-582-5057"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-18",
        "last_updated": "2012-10-19",
        "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": "NCPDP",
            "identifier": "1619331",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0174060",
            "state": "IA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0495291",
            "state": "IA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shopko Pharmacy 791",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Emily Elizabeth Putney, ATC
• Laura Raethke
• Michaela Schick
• Lauren Schumacher
• Brooke Shefchik
• The Evangelical Lutheran Good Samaritan Society
• Anne Tigges
• Jill Van Otterloo, PA
• Samantha Lynn Wedemeier, DPT
• Pamela Jean Westendorf, MS, ATC, LAT

• All providers in Forest City, IA
• Community/Retail Pharmacy in Iowa

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 19, 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.