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	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	332H00000X	Eyewear Supplier
3	3336C0003X	Community/Retail Pharmacy	1040	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	1619266	OTHER	NCPDP NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699726588
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOPKO STORES OPERATING CO LLC

Provider Business Mailing Address
First Line	:	4810 AVENUE O
Second Line	:
City	:	FORT MADISON
State	:	IA
Zip	:	52627-9677
Country	:	US
Telephone Number	:	319-372-8629
Fax Number	:	319-372-8698

Provider Business Practice Location Address
First Line	:	4810 AVENUE O
Second Line	:
City	:	FORT MADISON
State	:	IA
Zip	:	52627-9677
Country	:	US
Telephone Number	:	319-372-8629
Fax Number	:	319-372-8698

Authorized Official
Title or Position	:	SR. VICE PRESIDENT HEALTH SERVICES
Name	:	MR. MICHAEL J BETTIGA
Credential	:	RPH
Telephone Number	:	920-429-4297

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	07/25/2014

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Directions to “SHOPKO STORES OPERATING CO LLC ” Practice Location

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