Provider Demographics
NPI:1124214556
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 2528
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR 3D PARTY CONTRACT & CA, HEALTH
Authorized Official - Prefix:MS
Authorized Official - First Name:LORIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NEUMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-429-4726
Mailing Address - Street 1:148 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROUNDUP
Mailing Address - State:MT
Mailing Address - Zip Code:59072-2830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:148 MAIN ST
Practice Address - Street 2:
Practice Address - City:ROUNDUP
Practice Address - State:MT
Practice Address - Zip Code:59072-2830
Practice Address - Country:US
Practice Address - Phone:406-323-1811
Practice Address - Fax:406-323-1621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2783226OtherNCPDP
5695760273Medicare NSC