SHOPKO PHARMACY 119
Complete NPI Record 1376579334
Pharmacy - Community/Retail Pharmacy in Dixon, IL
Active since June 23, 2006
Complete NPI Dataset
This page contains the complete raw NPPES record for Shopko Pharmacy 119 (NPI 1376579334), a pharmacy organization in Dixon, IL. All 45 fields on file are listed with their current values and official NPPES definitions, exactly as recorded in the National Plan and Provider Enumeration System. Only fields that contain data are included, so the number of fields shown varies from one NPI record to another.
Use the tools below to filter fields by category, search within the record, or jump straight to a specific field. You can download the full record as a CSV, JSON, or text file, or filter first and export only the fields you need. The Print Clean Summary button produces a printer-friendly copy of the record.
Registry File Document Utilities
- NPI: 1376579334 Field 1/45
- The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
- Entity Type Code: 2 Field 2/45
- Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
- Employer Identification Number EIN: Not available Field 3/45
- The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
- Provider Organization Name Legal Business Name: SHOPKO STORES OPERATING CO LLC Field 4/45
- The name of the organization provider. If the provider is an organization, this is the legal business name.
- Provider Other Organization Name: SHOPKO PHARMACY 119 Field 5/45
- Other name by which the organization provider is or has been known.
- Provider Other Organization Name Type Code: 3 Field 6/45
- Code identifying the type of other name. Codes are: 1 = former name; 2 = professional name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other.
- Provider First Line Business Mailing Address: 1350 N GALENA AVE Field 7/45
- The first line mailing address of the provider being identified. This data element may contain the same information as "Provider first line location address".
- Provider Business Mailing Address City Name: DIXON Field 8/45
- The city name in the mailing address of the provider being identified.
- Provider Business Mailing Address State Name: IL Field 9/45
- The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address State name".
- Provider Business Mailing Address Postal Code: 610211010 Field 10/45
- The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as "Provider location address postal code".
- Provider Business Mailing Address Country Code If outside U S : US Field 11/45
- The country code in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address country code".
- Provider Business Mailing Address Telephone Number: 8152844127 Field 12/45
- The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as "Provider location address telephone number".
- Provider Business Mailing Address Fax Number: 8152846094 Field 13/45
- The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as "Provider location address fax number".
- Provider First Line Business Practice Location Address: 1350 N GALENA AVE Field 14/45
- The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
- Provider Business Practice Location Address City Name: DIXON Field 15/45
- The city name in the location address of the provider being identified.
- Provider Business Practice Location Address State Name: IL Field 16/45
- The State code in the location of the provider being identified.
- Provider Business Practice Location Address Postal Code: 610211010 Field 17/45
- The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
- Provider Business Practice Location Address Country Code If outside U S : US Field 18/45
- The country code in the location address of the provider being identified.
- Provider Business Practice Location Address Telephone Number: 8152844127 Field 19/45
- The telephone number associated with the location address of the provider being identified.
- Provider Business Practice Location Address Fax Number: 8152846094 Field 20/45
- The fax number associated with the location address of the provider being identified.
- Authorized Official Last Name: BETTIGA Field 23/45
- The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
- Authorized Official First Name: MICHAEL Field 24/45
- The first name of the authorized official.
- Authorized Official Middle Name: J Field 25/45
- The middle name of the authorized official.
- Authorized Official Title or Position: SR. VICE PRESIDENT HEALTH SERVICES Field 26/45
- The title or position of the authorized official.
- Authorized Official Telephone Number: 9204294297 Field 27/45
- The 10-position telephone number of the authorized official.
- Healthcare Provider Taxonomy Code 1: 332B00000X Field 28/45
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Healthcare Provider Primary Taxonomy Switch 1: N Field 29/45
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Healthcare Provider Taxonomy Code 2: 3336C0003X Field 30/45
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Provider License Number 2: 05401587 Field 31/45
- The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with "provider taxonomy code".
- Provider License Number State Code 2: IL Field 32/45
- The two-letter state code representing the U.S. state or territory that issued the provider's license. This field is linked to the Provider License Number field and identifies the jurisdiction where that license is valid. A provider may have multiple state codes if they hold licenses in more than one state.
- Healthcare Provider Primary Taxonomy Switch 2: Y Field 33/45
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Other Provider Identifier 1: =========008 Field 34/45
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 1: 05 Field 35/45
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 1: IL Field 36/45
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Other Provider Identifier 2: 1463809 Field 37/45
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 2: 01 Field 38/45
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier Issuer 2: NCPDP NUMBER Field 39/45
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Other Provider Identifier 3: 410985054001 Field 40/45
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 3: 05 Field 41/45
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 3: IL Field 42/45
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Is Organization Subpart: N Field 43/45
- Indicates whether the provider is a subpart of a larger organization. This is a single-character code: "Y" means the entity is an organizational subpart, while "N" means it is not. Subparts typically include hospital departments, clinics, or other distinct units that fall under a parent organization.
- Authorized Official Name Prefix Text: MR. Field 44/45
- The prefix used in the name of the authorized official associated with the provider's NPI record. Examples include Mr., Ms., Mrs., Dr., or other common professional or personal prefixes.
- Authorized Official Credential Text: RPH Field 45/45
- The professional credential(s) of the authorized official listed on the provider's NPI record. Examples include MD (Doctor of Medicine), DO (Doctor of Osteopathy), RN (Registered Nurse), DDS (Doctor of Dental Surgery), PhD, or other recognized designations that reflect the official's qualifications.
Other Provider Identifiers 5
Legacy and payer-issued identifiers reported to the NPPES registry for this provider.
=========008 Medicaid
Identifier 1/5State: IL
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
0154160211 Medicare ID-Type Unspecified
Identifier 2/5Medicare ID (Type Unspecified): A Medicare-issued provider identifier whose specific subtype or program context has not been designated.
1463809 Other
Identifier 3/5Issuer: Ncpdp Number
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
410985054001 Medicaid
Identifier 4/5State: IL
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
5695760131 Medicare NSC
Identifier 5/5Medicare NSC: Used in the "Other Provider Identifier" field when listing non-NPI legacy provider numbers associated with a health care practitioner or organization in NPPES.
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