Provider Demographics
NPI:1003349101
Name:SHOPKO STORES OPERATING CO., LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO., LLC
Other - Org Name:SHOPKO PHARMACY 2215
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:JANNIE
Authorized Official - Middle Name:DELANE
Authorized Official - Last Name:PASCHAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-429-4726
Mailing Address - Street 1:100 COUNTY ROAD B STE W181
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-7072
Mailing Address - Country:US
Mailing Address - Phone:715-526-3456
Mailing Address - Fax:
Practice Address - Street 1:100 COUNTY ROAD B
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-7072
Practice Address - Country:US
Practice Address - Phone:920-429-4726
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-05
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1003349101Medicaid