Provider Demographics
NPI:1417304544
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 596
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF THIRD PARTY
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 1:1208 N. HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:DELL RAPIDS
Mailing Address - State:SD
Mailing Address - Zip Code:57022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1208 N. HIGHWAY 77
Practice Address - Street 2:
Practice Address - City:DELL RAPIDS
Practice Address - State:SD
Practice Address - Zip Code:57022
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:2016-05-18
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1417304544Medicaid
SD1417304544Medicaid