Healthcare Provider Details

I. General information

NPI: 1174576763
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: 01/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2353 SOUTH E
BROKEN BOW NE
68822-2031
US

IV. Provider business mailing address

PO BOX 383
BROKEN BOW NE
68822-0383
US

V. Phone/Fax

Practice location:
  • Phone: 308-872-6818
  • Fax: 308-872-6889
Mailing address:
  • Phone: 308-872-6818
  • Fax: 308-872-6889

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