Healthcare Provider Details

I. General information

NPI: 1225320419
Provider Name (Legal Business Name): SHOPKO STORES OPERATING CO., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2011
Last Update Date: 01/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 SMITH ST
BLOOMFIELD IA
52537-2140
US

IV. Provider business mailing address

106 SMITH ST
BLOOMFIELD IA
52537-2140
US

V. Phone/Fax

Practice location:
  • Phone: 641-664-2349
  • Fax: 641-664-2464
Mailing address:
  • Phone: 641-664-2349
  • Fax: 641-664-2464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

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