Healthcare Provider Details

I. General information

NPI: 1104870880
Provider Name (Legal Business Name): SHOPKO STORES OPERATING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 08/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 4TH AVE S
PARK FALLS WI
54552-1926
US

IV. Provider business mailing address

1333 4TH AVE S
PARK FALLS WI
54552-1926
US

V. Phone/Fax

Practice location:
  • Phone: 715-762-4764
  • Fax: 715-762-4934
Mailing address:
  • Phone: 715-762-4764
  • Fax: 715-762-4934

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