Provider Demographics
NPI:1144260571
Name:SHOPKO STORES OPERATING CO LLC
Entity type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VICE PRESIDENT HEALTH SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BETTIGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-429-4297
Mailing Address - Street 1:1651 W ROSE ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-1771
Mailing Address - Country:US
Mailing Address - Phone:509-525-9207
Mailing Address - Fax:509-529-7061
Practice Address - Street 1:1651 W ROSE ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-1771
Practice Address - Country:US
Practice Address - Phone:509-525-9207
Practice Address - Fax:509-529-7061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332H00000X
WACF000586483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
0215798OtherWA LABOR & INDUSTRY
OR278381Medicaid
OR278351Medicaid
0050989OtherWA LABOR & INDUSTRY
OR029348Medicaid
4919695OtherNCPDP NUMBER
WA0006130033Medicaid
0050989OtherWA LABOR & INDUSTRY
OR029348Medicaid
5695760116Medicare NSC