Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

9005-042 Issued in WI

Legal business name

SHOPKO STORES OPERATING CO LLC

Practice address

126 Charles St
Oconto, WI 54153-9446

Phone

(920) 834-9800

Fax

(920) 834-9801

NPI assigned

May 17, 2010

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 4

Addresses

Other identifiers 1

Other names 1

• ShopKo Pharmacy 602 Doing business as

Locations

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

{
    "created_epoch": "1274054400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1311638400000",
    "number": "1982922860",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "126 CHARLES ST",
            "city": "OCONTO",
            "state": "WI",
            "postal_code": "541539446",
            "telephone_number": "920-834-9800",
            "fax_number": "920-834-9801"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "126 CHARLES ST",
            "city": "OCONTO",
            "state": "WI",
            "postal_code": "541539446",
            "telephone_number": "920-834-9800",
            "fax_number": "920-834-9801"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-05-17",
        "last_updated": "2011-07-26",
        "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": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "state": "WI",
            "license": "456-1020161146-03",
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "WI",
            "license": "9005-042",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1982922860",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 602",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Megan Ann Robers, PT, DPT
• Elizabeth Joyce Russell, M.D.
• David Schreiter, CSAC
• Shopko #602
• Shopko Stores Operating Co LLC
• Joshua M Simpson, DMD
• Marissa Spatz
• St Clare Memorial Hospital, Inc
• St Vincent Hospital-Hospital Sisters-Third Order of St Francis
• St Vincent Hospital-Hospital Sisters-Third Order of St Francis

• Community/Retail Pharmacy in Oconto, WI
• Providers in Oconto, 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 26, 2011; 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.