Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

8614042 Issued in WI

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

ShopKo Pharmacy 001

Practice address

216 S Military Ave
Green Bay, WI 54303-2498

Phone

(920) 499-0895

Fax

(920) 494-3410

NPI assigned

May 24, 2006

Last updated

Jun 6, 2014By the provider in NPPES

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 4

Addresses

Other identifiers 2

Other names 1

• ShopKo Pharmacy 001 Doing business as

Locations

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

{
    "created_epoch": "1148428800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1402012800000",
    "number": "1982659140",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "216 S MILITARY AVE",
            "city": "GREEN BAY",
            "state": "WI",
            "postal_code": "543032498",
            "telephone_number": "920-499-0895",
            "fax_number": "920-494-3410"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "216 S MILITARY AVE",
            "city": "GREEN BAY",
            "state": "WI",
            "postal_code": "543032498",
            "telephone_number": "920-499-0895",
            "fax_number": "920-494-3410"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-24",
        "last_updated": "2014-06-06",
        "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": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "WI",
            "license": "8614042",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "5103508",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "33136200",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 001",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Shopko Stores Operating Co LLC (ShopKo Pharmacy 002)
• Shopko Stores Operating Co LLC (ShopKo Pharmacy 506)
• Shopko Stores Operating Co LLC
• Shopko Stores Operating Co LLC (ShopKo Express Pharmacy 502)
• Shopko Stores Operating Co LLC (ShopKo Optical 177)
• Shopko Stores Operating Co. LLC (ShopKo Optical 002)
• Shopko Stores Operating Co. LLC (ShopKo Optical 001)
• Shopko Stores Operating Co. LLC (ShopKo Optical 004)
• Shopko Stores Operating Co. LLC (ShopKo Optical 502)
• Shopko Stores Operating Co. LLC (ShopKo Optical)

• Community/Retail Pharmacy in Green Bay, WI
• Providers in Green Bay, 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 Jun 6, 2014; 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.