Healthcare Provider Details

I. General information

NPI: 1447203799
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: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 GATEWAY DR NE
EAST GRAND FORKS MN
56721-1619
US

IV. Provider business mailing address

421 GATEWAY DR NE
EAST GRAND FORKS MN
56721-1619
US

V. Phone/Fax

Practice location:
  • Phone: 218-773-0940
  • Fax: 218-773-1049
Mailing address:
  • Phone: 218-773-0940
  • Fax: 218-773-1049

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

VIII. Authorized Official

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