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NPI Code Detail

MEDICARE: SHOPKO STORES OPERATING CO LLC

MEDICARE: SHOPKO STORES OPERATING CO LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1332B00000XDurable Medical Equipment & Medical Supplies
2333600000XPharmacy
3332H00000XEyewear Supplier
43336C0003XCommunity/Retail Pharmacy8636042WI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
15103926OTHERNCPDP NUMBER
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1003862442
Entity Type Code : Organization
Provider Name (Legal Business Name) : SHOPKO STORES OPERATING CO LLC
Provider Business Mailing Address
First Line : 2430 E MASON ST
Second Line :
City : GREEN BAY
State : WI
Zip : 54302-3759
Country : US
Telephone Number : 920-468-6044
Fax Number : 920-468-3490
Provider Business Practice Location Address
First Line : 2430 E MASON ST
Second Line :
City : GREEN BAY
State : WI
Zip : 54302-3759
Country : US
Telephone Number : 920-468-6044
Fax Number : 920-468-3490
Authorized Official
Title or Position : SR. VICE PRESIDENT HEALTH SERVICES
Name : MR. MICHAEL J BETTIGA
Credential : RPH
Telephone Number : 920-429-4297
Provider Enumeration Date : 05/26/2006
Last Update Date : 02/14/2014

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2430 E MASON ST
GREEN BAY, WI
54302-3759
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Directions to “SHOPKO STORES OPERATING CO LLC ” Practice Location

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