Provider Demographics
NPI:1366828642
Name:SHOPKO STORES OPERATING CO., LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO., LLC
Other - Org Name:SHOPKO PHARMACY #2799
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR 3D PARTY CONTRACT & CA
Authorized Official - Prefix:
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 1:440 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TREMONTON
Mailing Address - State:UT
Mailing Address - Zip Code:84337
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:440 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TREMONTON
Practice Address - State:UT
Practice Address - Zip Code:84337
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:2015-08-10
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1366828642Medicaid
UT5695760296Medicare NSC