Provider Demographics
NPI:1831515766
Name:SHOPKO INSTITUTIONAL CARE SERVICES CO LLC
Entity type:Organization
Organization Name:SHOPKO INSTITUTIONAL CARE SERVICES CO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT AND COO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BETTIGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-429-4297
Mailing Address - Street 1:150 N PATRICK BLVD
Mailing Address - Street 2:250
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5892
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 N PATRICK BLVD
Practice Address - Street 2:250
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5892
Practice Address - Country:US
Practice Address - Phone:920-429-2211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
WI9248-423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies