=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972539740
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHOPKO STORES OPERATING CO. LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2006
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 N MAIN ST
-----------------------------------------------------
City | EAST PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61611-2543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-699-0632
-----------------------------------------------------
Fax | 309-694-6426
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 N MAIN ST
-----------------------------------------------------
City | EAST PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61611-2543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-699-0632
-----------------------------------------------------
Fax | 309-694-6426
-----------------------------------------------------
=====================================================
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 | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------