Provider Demographics
NPI:1639121155
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 111
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP CHIEF FINANCIAL OFFICER
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 1:1230 LANCASTER DR SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97317-5800
Mailing Address - Country:US
Mailing Address - Phone:503-371-6830
Mailing Address - Fax:503-371-8159
Practice Address - Street 1:1230 LANCASTER DR SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97317-5800
Practice Address - Country:US
Practice Address - Phone:503-371-6830
Practice Address - Fax:503-371-8159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332H00000X
OR11933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
3810721OtherNCPDP NUMBER
OR278347Medicaid
OR038658Medicaid
OR278380Medicaid
5695760009Medicare NSC
3810721OtherNCPDP NUMBER