Healthcare Provider Details

I. General information

NPI: 1477732022
Provider Name (Legal Business Name): SHOPKO STORES OPERATING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 02/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 S MAIN
SMTIH CENTER KS
66967
US

IV. Provider business mailing address

PO BOX 1450 NW 5891
MINNEAPOLIS MN
55485-5891
US

V. Phone/Fax

Practice location:
  • Phone: 785-282-6443
  • Fax: 785-282-3550
Mailing address:
  • Phone: 785-282-6443
  • Fax: 785-282-3550

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
Identifier200389320I
Identifier TypeMEDICAID
Identifier StateKS
Identifier Issuer

VIII. Authorized Official

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