Provider Demographics
NPI:1588848295
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 2656
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP 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 1:748 S CEDAR ST STE E
Mailing Address - Street 2:
Mailing Address - City:KALKASKA
Mailing Address - State:MI
Mailing Address - Zip Code:49646-8434
Mailing Address - Country:US
Mailing Address - Phone:231-258-0139
Mailing Address - Fax:231-258-5488
Practice Address - Street 1:748 S CEDAR ST STE E
Practice Address - Street 2:
Practice Address - City:KALKASKA
Practice Address - State:MI
Practice Address - Zip Code:49646-8434
Practice Address - Country:US
Practice Address - Phone:231-258-0139
Practice Address - Fax:231-258-5488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
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
MI2370598Medicaid
5695760222Medicare NSC