Provider Demographics
NPI:1912398736
Name:SHOPKO STORES OPERATING CO., LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO., LLC
Other - Org Name:SHOPKO PHARMACY 795
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR 3D PARTY CONTRACT & CA
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 1:1026 S CHALLIS ST
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-5441
Mailing Address - Country:US
Mailing Address - Phone:208-742-1285
Mailing Address - Fax:208-742-1283
Practice Address - Street 1:1026 S CHALLIS ST
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-5441
Practice Address - Country:US
Practice Address - Phone:208-742-1285
Practice Address - Fax:208-742-1283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-16
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1912398736Medicaid
5695760295Medicare NSC