Healthcare Provider Details

I. General information

NPI: 1558313908
Provider Name (Legal Business Name): SHOPKO STORES OPERATING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 08/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 CHAD DR
EUGENE OR
97408-7335
US

IV. Provider business mailing address

2815 CHAD DR
EUGENE OR
97408-7335
US

V. Phone/Fax

Practice location:
  • Phone: 541-686-0094
  • Fax: 541-338-9894
Mailing address:
  • Phone: 541-686-0094
  • Fax: 541-338-9894

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 TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1086
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier278379
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier3809970
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP NUMBER
# 3
Identifier000690
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 4
Identifier278348
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

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