Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

Shopko Pharmacy 686

Practice address

902 S Locust St
Glenwood, IA 51534-1834

Phone

(712) 527-9200

Fax

(712) 527-5836

NPI assigned

May 19, 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 and Coo

Phone

(920) 429-4297

Specialties & licenses 3

Addresses

Other identifiers 4

Other names 1

• Shopko Pharmacy 686 Doing business as

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

• Shopko Stores Operating Co LLC

  dba Shopko Pharmacy 750

  • Community/Retail Pharmacy
  • Windom, MN
  • NPI 1952354177

  Member Of

  NPD member

Locations

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

{
    "created_epoch": "1147996800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1350432000000",
    "number": "1982657912",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "902 S LOCUST ST",
            "city": "GLENWOOD",
            "state": "IA",
            "postal_code": "515341834",
            "telephone_number": "712-527-9200",
            "fax_number": "712-527-5836"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "902 S LOCUST ST",
            "city": "GLENWOOD",
            "state": "IA",
            "postal_code": "515341834",
            "telephone_number": "712-527-9200",
            "fax_number": "712-527-5836"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-19",
        "last_updated": "2012-10-17",
        "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": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP",
            "identifier": "1620853",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0495929",
            "state": "IA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10025460600",
            "state": "NE"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0223735",
            "state": "IA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shopko Pharmacy 686",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Michael Dale Schmiesing, M.D.
• Self
• Dana Sharp, TLMHC
• Alexandria Christine Shehan, RBT
• Dominic Shiu, M.D.
• Ronald D Silvius, D.O.
• Simply Young, LLC
• Amanda A. Smith, MSN, APRN
• Southwest Iowa Medical Services Inc (Southwest Iowa Medical Equipment)
• Tammy Lea Squier

• Community/Retail Pharmacy in Glenwood, IA
• Providers in Glenwood, IA by specialty
• Community/Retail Pharmacy in Iowa

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 17, 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.