Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

1327651703 Issued in UT

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

ShopKo Pharmacy 109

Practice address

4060 Riverdale Rd
Riverdale, UT 84405-1518

Phone

(801) 392-6800

Fax

(801) 392-5389

NPI assigned

May 13, 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 J Bettiga, RPH

Title

Sr. Vice President Health Services

Phone

(920) 429-4297

Specialties & licenses 2

Addresses

Other identifiers 2

Other names 1

• ShopKo Pharmacy 109 Doing business as

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

{
    "created_epoch": "1147478400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1218672000000",
    "number": "1952352932",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4060 RIVERDALE RD",
            "city": "RIVERDALE",
            "state": "UT",
            "postal_code": "844051518",
            "telephone_number": "801-392-6800",
            "fax_number": "801-392-5389"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4060 RIVERDALE RD",
            "city": "RIVERDALE",
            "state": "UT",
            "postal_code": "844051518",
            "telephone_number": "801-392-6800",
            "fax_number": "801-392-5389"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-13",
        "last_updated": "2008-08-14",
        "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": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "UT",
            "license": "1327651703",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "4607353",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "410985054201",
            "state": "UT"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 109",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• James Alan Schultz, CSW
• Tallin McKay Sepulveda
• Serenity Lactation
• Serenity Springs Counseling and Wellness
• Gabriella Serrano
• Shopko Stores Operating Co. LLC
• Annie Smith
• Aubrey Smith
• Madeline Smith, LCSW
• Madison Smith, BSN, RN, IBCLC

• Community/Retail Pharmacy in Riverdale, UT
• Providers in Riverdale, UT by specialty
• Community/Retail Pharmacy in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 14, 2008; 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.