Healthcare Provider Details

I. General information

NPI: 1457302028
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: 06/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 N MAIN ST
MITCHELL SD
57301-1160
US

IV. Provider business mailing address

1900 N MAIN ST
MITCHELL SD
57301-1160
US

V. Phone/Fax

Practice location:
  • Phone: 605-996-6568
  • Fax: 605-996-6627
Mailing address:
  • Phone: 605-996-6568
  • Fax: 605-996-6627

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 Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1001905
License Number StateSD

VII. Legacy identifiers

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

# 1
Identifier8500490
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 2
Identifier8500492
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 3
Identifier4300505
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP NUMBER
# 4
Identifier9164970
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 5
Identifier9164972
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

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