Healthcare Provider Details

I. General information

NPI: 1295788891
Provider Name (Legal Business Name): SHOPKO STORES OPERATING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 01/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 S COUNTY RD
TOLEDO IA
52342-1062
US

IV. Provider business mailing address

1006 S COUNTY RD
TOLEDO IA
52342-1062
US

V. Phone/Fax

Practice location:
  • Phone: 641-484-8801
  • Fax: 641-484-8701
Mailing address:
  • Phone: 641-484-8801
  • Fax: 641-484-8701

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:

# 1
Identifier0299321
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier0495598
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 3
Identifier1621704
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP

VIII. Authorized Official

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