=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306897384
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHOPKO STORES OPERATING CO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2006
-----------------------------------------------------
Last Update Date | 08/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2290 S 1300 E
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84106-2831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-467-8900
-----------------------------------------------------
Fax | 801-467-8291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2290 S 1300 E
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84106-2831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-467-8900
-----------------------------------------------------
Fax | 801-467-8291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR. VICE PRESIDENT HEALTH SERVICES
-----------------------------------------------------
Name | MR. MICHAEL J BETTIGA
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 920-429-4297
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 1332031703
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------