Healthcare Provider Details

I. General information

NPI: 1255378907
Provider Name (Legal Business Name): SHOPKO STORES OPERATING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 06/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4215 YELLOWSTONE AVE
CHUBBUCK ID
83202-2419
US

IV. Provider business mailing address

4215 YELLOWSTONE AVE
CHUBBUCK ID
83202-2419
US

V. Phone/Fax

Practice location:
  • Phone: 208-237-6828
  • Fax: 208-238-8371
Mailing address:
  • Phone: 208-237-6828
  • Fax: 208-238-8371

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 Number2039CP
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2039CP
License Number StateID

VIII. Authorized Official

Name: MR. MICHAEL J BETTIGA
Title or Position: SR. VICE PRESIDENT HEALTH SERVICES
Credential: RPH
Phone: 920-429-4297