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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	5127267	OTHER		NCPDP NUMBER

General Provider Information

NPI Number	:	1821042003
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOPKO STORES OPERATING CO LLC

Provider Business Mailing Address
First Line	:	291 S MAIN ST
Second Line	:
City	:	CLINTONVILLE
State	:	WI
Zip	:	54929-1604
Country	:	US
Telephone Number	:	715-823-2350
Fax Number	:	715-823-2541

Provider Business Practice Location Address
First Line	:	291 S MAIN ST
Second Line	:
City	:	CLINTONVILLE
State	:	WI
Zip	:	54929-1604
Country	:	US
Telephone Number	:	715-823-2350
Fax Number	:	715-823-2541

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

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	09/24/2012

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