Basic Information
| Provider Information | |||||||||
| NPI: | 1083819239 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHOPKO STORES OPERATING CO LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SHOPKO PHARMACY 710 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 212 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | GALLATIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 646401150 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 212 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | GALLATIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 646401150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1111111111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 08/28/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BETTIGA | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT & COO | ||||||||
| AuthorizedOfficialTelephone: | 9204294297 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | RPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.