Provider Demographics
NPI:1427007160
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 2011
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP AND CFO
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 1:500 S CARPENTER AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49802-4529
Mailing Address - Country:US
Mailing Address - Phone:906-774-7907
Mailing Address - Fax:906-774-5547
Practice Address - Street 1:500 S CARPENTER AVE
Practice Address - Street 2:
Practice Address - City:KINGSFORD
Practice Address - State:MI
Practice Address - Zip Code:49802-4529
Practice Address - Country:US
Practice Address - Phone:906-774-7907
Practice Address - Fax:906-774-5547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332H00000X, 333600000X
MI53010083633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33127600Medicaid
2321418OtherNCPDP NUMBER
MI2321418Medicaid
MI9000B210480OtherBLUE CROSS PIN
4819031OtherMI MEDICAID DME
4913374OtherMI MEDICAID DME
4819031OtherMI MEDICAID DME
WI33127600Medicaid