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 178

Practice address

N 66 W 25201
CTH V V
Sussex, WI 53089

Phone

(262) 820-2611

Fax

(262) 820-2592

NPI assigned

Jun 23, 2008

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

Sr Vice President Health Services

Phone

(920) 429-4297

Specialties & licenses 4

Addresses

Other identifiers 3

Other names 1

• ShopKo Pharmacy 178 Doing business as

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

{
    "created_epoch": "1214179200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1406246400000",
    "number": "1982865945",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "N66 W 25201 CTH V V",
            "city": "SUSSEX",
            "state": "WI",
            "postal_code": "53089"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "N 66 W 25201",
            "address_2": "CTH V V",
            "city": "SUSSEX",
            "state": "WI",
            "postal_code": "53089",
            "telephone_number": "262-820-2611",
            "fax_number": "262-820-2592"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-06-23",
        "last_updated": "2014-07-25",
        "status": "A",
        "authorized_official_last_name": "BETTIGA",
        "authorized_official_first_name": "MICHAEL",
        "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": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "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": "5131014",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDCO",
            "identifier": "488000297",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "36229200",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 178",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Kimberly Rose Schwingle, LPC
• Ann J Shallue, D.O.
• Halee Shepard, DPT
• Amanda Shober
• Shopko Stores Operating Co LLC
• SHS Senior Services, LLC.
• Catherine Simmons
• Robert Jack Simons, D.C.
• Samantha Sippl, APNP
• Ellen Smith

• Community/Retail Pharmacy in Sussex, WI
• Providers in Sussex, 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 Jul 25, 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.