Provider Demographics
NPI:1508819392
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 2648
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 1:2655 W CHICAGO BLVD
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286
Mailing Address - Country:US
Mailing Address - Phone:517-423-4420
Mailing Address - Fax:517-423-7610
Practice Address - Street 1:2655 W CHICAGO BLVD
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286
Practice Address - Country:US
Practice Address - Phone:517-423-4420
Practice Address - Fax:517-423-7610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2353186OtherNCPDP NUMBER
MI2353186Medicaid
MI3081011Medicaid
MI4913839Medicaid
MI3082645Medicaid
0P42860Medicare PIN
MI3082645Medicaid
MI4913839Medicaid