Healthcare Provider Details

I. General information

NPI: 1407127889
Provider Name (Legal Business Name): SHOPKO STORES OPERATING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2012
Last Update Date: 04/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 N MAIN ST
LAKE MILLS WI
53551-1610
US

IV. Provider business mailing address

203 N MAIN ST
LAKE MILLS WI
53551-1610
US

V. Phone/Fax

Practice location:
  • Phone: 920-648-3455
  • Fax: 920-648-2712
Mailing address:
  • Phone: 920-648-3455
  • Fax: 920-648-2712

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: MICHAEL BETTIGA
Title or Position: EXECUTIVE VICE PRESIDENT AND COO
Credential: RPH
Phone: 920-429-4297