Provider Demographics
NPI:1649222878
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
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 1:3044 S 84TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-3208
Mailing Address - Country:US
Mailing Address - Phone:402-391-1143
Mailing Address - Fax:
Practice Address - Street 1:3044 S 84TH ST STE 1
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-3208
Practice Address - Country:US
Practice Address - Phone:402-391-1143
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
35504OtherAVESIS
17884OtherMEDICARE
260474OtherMEDICARE
NE41098505418Medicaid
007124OtherBLOCK
014044OtherVIP
35860OtherDAVIS
CP2230-31OtherEYEMED
007124OtherBLOCK
35504OtherAVESIS
17884OtherMEDICARE
DF0848Medicare PIN