NPIMap

Organization Active NPI

Shopko Stores Operating Co. LLC

  • Durable Medical Equipment & Medical Supplies
  • East Peoria, IL
National Provider Identifier
1972539740
Registry record updated Sep 11, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Durable Medical Equipment & Medical SuppliesTaxonomy code 332B00000X
Legal business name
SHOPKO STORES OPERATING CO. LLC
Practice address
105 N Main St
East Peoria, IL 61611-2543
Phone
(309) 699-0632
Fax
(309) 694-6426
NPI assigned
Jun 24, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 11, 2025

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

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X Primary
Community/Retail Pharmacy 3336C0003X IL

Addresses

Primary practice location

105 N Main St
East Peoria, IL 61611-2543

Mailing address

105 N Main St
East Peoria, IL 61611-2543
Phone (309) 699-0632

Other identifiers 2

IdentifierTypeStateIssuer
1472048OtherNCPDP NUMBER
410985054173MedicaidIL

Other names 1

  • ShopKo Pharmacy 173 Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Shopko Stores Operat Co LLC16 organizations share this tax ID, including this one

Other organizations with this tax ID 15

Organizations that report the same tax identification number in the National Provider Directory.

View all 15

Locations

105 N Main St
East Peoria, IL 61611
Phone (309) 694-6470

NPI Registry JSON

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

{
    "created_epoch": "1151107200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1757548800000",
    "number": "1972539740",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "105 N MAIN ST",
            "city": "EAST PEORIA",
            "state": "IL",
            "postal_code": "616112543",
            "telephone_number": "309-699-0632",
            "fax_number": "309-694-6426"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "105 N MAIN ST",
            "city": "EAST PEORIA",
            "state": "IL",
            "postal_code": "616112543",
            "telephone_number": "309-699-0632",
            "fax_number": "309-694-6426"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO. LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-24",
        "last_updated": "2025-09-11",
        "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": true
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "IL",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "1472048",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "410985054173",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 173",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in East Peoria, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 11, 2025; 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.