MEDICARE: SHOPKO STORES OPERATING CO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5124893	OTHER		NCPDP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578518205
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOPKO STORES OPERATING CO LLC

Provider Business Mailing Address
First Line	:	1625 US HIGHWAY 61
Second Line	:
City	:	LANCASTER
State	:	WI
Zip	:	53813-9448
Country	:	US
Telephone Number	:	608-723-7679
Fax Number	:	608-723-6202

Provider Business Practice Location Address
First Line	:	1625 US HIGHWAY 61
Second Line	:
City	:	LANCASTER
State	:	WI
Zip	:	53813-9448
Country	:	US
Telephone Number	:	608-723-7679
Fax Number	:	608-723-6202

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT & COO
Name	:	MR. MICHAEL BETTIGA
Credential	:	RPH
Telephone Number	:	920-429-4297

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	09/13/2012

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