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
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1184895336
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOPKO STORES OPERATING CO LLC

Provider Business Mailing Address
First Line	:	PO BOX 399
Second Line	:	1960 SOUTH MOREY ROAD
City	:	LAKE CITY
State	:	MI
Zip	:	49651
Country	:	US
Telephone Number	:	231-839-7207
Fax Number	:	231-839-4142

Provider Business Practice Location Address
First Line	:	1960 SOUTH MOREY ROAD
Second Line	:
City	:	LAKE CITY
State	:	MI
Zip	:	49651
Country	:	US
Telephone Number	:	231-839-7207
Fax Number	:	231-839-4142

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT & COO
Name	:	MR. MICHAEL BETTIGA
Credential	:	RPH
Telephone Number	:	920-429-4297

Provider Enumeration Date	:	03/17/2008
Last Update Date	:	02/15/2013

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