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General NPI Number Information
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NPI Number | 1659322543
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Entity Type | Organization
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Legal Business Name | SHOPKO STORES OPERATING CO LLC
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Dates
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Enumeration Date | 05/15/2006
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Last Update Date | 06/06/2014
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Provider Practice Location Address
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Address Line | 1601 W 41ST ST
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City | SIOUX FALLS
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State | SD
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Zip | 57105-6371
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Country | US
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Telephone | 605-338-3155
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Fax | 605-334-4915
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Provider Business Mailing Address
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Address Line | 1601 W 41ST ST
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City | SIOUX FALLS
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State | SD
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Zip | 57105-6371
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Country | US
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Telephone | 605-338-3155
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Fax | 605-334-4915
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Authorized Official
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Title or Position | SR. VICE PRESIDENT HEALTH SERVICES
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Name | MR. MICHAEL J BETTIGA
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Credential | RPH
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Telephone | 920-429-4297
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 1001908
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License Number State | SD
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