Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

9006-042 Issued in WI

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

Shopko Pharmacy 601

Practice address

802 N Main St
Kewaunee, WI 54216-0274

Phone

(920) 388-2231

Fax

(920) 388-2459

NPI assigned

May 19, 2010

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 and Coo

Phone

(920) 429-4297

Specialties & licenses 3

Addresses

Other identifiers 1

Other names 1

• Shopko Pharmacy 601 Doing business as

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

{
    "created_epoch": "1274227200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1285113600000",
    "number": "1891014635",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "802 N MAIN ST",
            "address_2": "PO BOX 274",
            "city": "KEWAUNEE",
            "state": "WI",
            "postal_code": "542160274",
            "telephone_number": "920-388-2231",
            "fax_number": "920-388-2459"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "802 N MAIN ST",
            "city": "KEWAUNEE",
            "state": "WI",
            "postal_code": "542160274",
            "telephone_number": "920-388-2231",
            "fax_number": "920-388-2459"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-05-19",
        "last_updated": "2010-09-22",
        "status": "A",
        "authorized_official_last_name": "BETTIGA",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_title_or_position": "EXECUTIVE VICE PRESIDENT AND 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": "WI",
            "license": "9006-042",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1891014635",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shopko Pharmacy 601",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Thomas James Rydzewski, RPH
• Anthony Michael Sachse, PT, LAT
• John E Schad, LPC
• Richard James Seifert, MSW CICSW ACSW
• Jerry Michael Selner
• Charles L Sivret, DC
• Marie G Smith, RD
• Paul M Smullen, MD
• Brian Daniel Sperber, D.D.S.
• St. Vincent Hospital-Hospital Sisters-Third Order of St. Francis

• Community/Retail Pharmacy in Kewaunee, WI
• Providers in Kewaunee, 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 22, 2010; 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.