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General NPI Number Information
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NPI Number | 1992007926
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Entity Type | Organization
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Legal Business Name | SHOPKO INSTITUTIONAL CARE SERVICES
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Dates
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Enumeration Date | 11/24/2010
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Last Update Date | 12/13/2010
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Provider Practice Location Address
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Address Line | 700 PILGRIM WAY
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City | GREEN BAY
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State | WI
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Zip | 54304-5263
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Country | US
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Telephone | 920-429-4218
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Fax | 920-429-5218
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Provider Business Mailing Address
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Address Line | 700 PILGRIM WAY
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City | GREEN BAY
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State | WI
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Zip | 54304-5263
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Country | US
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Telephone | 920-429-4218
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Fax | 920-429-5218
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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 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 | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number |
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License Number State |
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