Provider Demographics
NPI:1821441205
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 584
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF THIRD PARTY
Authorized Official - Prefix:
Authorized Official - First Name:LORIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NEUMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-429-4726
Mailing Address - Street 1:6355 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-8519
Mailing Address - Country:US
Mailing Address - Phone:920-429-4726
Mailing Address - Fax:
Practice Address - Street 1:6355 MAIN ST
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-8519
Practice Address - Country:US
Practice Address - Phone:920-429-4726
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-20
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID5695760304Medicare NSC