Healthcare Provider Details

I. General information

NPI: 1568401453
Provider Name (Legal Business Name): SHOPKO STORES OPERATING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 10/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S 20TH ST
WORLAND WY
82401-3742
US

IV. Provider business mailing address

100 S 20TH ST
WORLAND WY
82401-3742
US

V. Phone/Fax

Practice location:
  • Phone: 307-347-2851
  • Fax: 307-347-2651
Mailing address:
  • Phone: 307-347-2851
  • Fax: 307-347-2651

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