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General NPI Number Information
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NPI Number | 1790095099
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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 | 10/20/2010
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Last Update Date | 12/09/2011
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Provider Practice Location Address
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Address Line | 1010 S MAINLINE DR
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City | SEYMOUR
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State | WI
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Zip | 54165-1150
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Country | US
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Telephone | 920-833-0430
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Fax | 920-833-7556
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Provider Business Mailing Address
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Address Line | 1010 S MAINLINE DR
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City | SEYMOUR
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State | WI
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Zip | 54165-1150
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Country | US
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Telephone | 920-883-0430
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Fax | 920-883-7556
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Authorized Official
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Title or Position | EXECUTIVE VICE PRESIDENT AND COO
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Name | MR. MICHAEL 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 | 333600000X
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Taxonomy Name | Pharmacy
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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 | 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 #4
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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