Healthcare Provider Details

I. General information

NPI: 1639120611
Provider Name (Legal Business Name): SHOPKO STORES OPERATING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 08/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 S STATE ST
OREM UT
84058-5419
US

IV. Provider business mailing address

125 S STATE ST
OREM UT
84058-5419
US

V. Phone/Fax

Practice location:
  • Phone: 801-224-9800
  • Fax: 801-224-1720
Mailing address:
  • Phone: 801-224-9800
  • Fax: 801-224-1720

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 Number1326041703
License Number StateUT

VII. Legacy identifiers

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

# 1
Identifier410985054182
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer
# 2
Identifier4607238
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP NUMBER
# 3
Identifier4607238
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

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