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	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	100-1902	SD

General Provider Information

NPI Number	:	1942253802
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOPKO STORES OPERATING CO LLC

Provider Business Mailing Address
First Line	:	800 S WASHINGTON AVE
Second Line	:
City	:	MADISON
State	:	SD
Zip	:	57042-3520
Country	:	US
Telephone Number	:	605-256-6169
Fax Number	:	605-256-6461

Provider Business Practice Location Address
First Line	:	800 S WASHINGTON AVE
Second Line	:
City	:	MADISON
State	:	SD
Zip	:	57042-3520
Country	:	US
Telephone Number	:	605-256-6169
Fax Number	:	605-256-6461

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

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	10/01/2012

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