Provider Demographics
NPI:1427001056
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 2650
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP AND COO
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:STEINHORST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-429-7489
Mailing Address - Street 1:56419 POKAGON ST
Mailing Address - Street 2:
Mailing Address - City:DOWAGIAC
Mailing Address - State:MI
Mailing Address - Zip Code:49047-7721
Mailing Address - Country:US
Mailing Address - Phone:269-782-0280
Mailing Address - Fax:269-782-0282
Practice Address - Street 1:56419 POKAGON ST
Practice Address - Street 2:
Practice Address - City:DOWAGIAC
Practice Address - State:MI
Practice Address - Zip Code:49047-7721
Practice Address - Country:US
Practice Address - Phone:269-782-0280
Practice Address - Fax:269-782-0282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC540A410170Medicaid
MI4913436Medicaid
2367096OtherNCPDP NUMBER
MI2367096Medicaid
MI4819274Medicaid
2367096OtherNCPDP NUMBER