Provider Demographics
NPI:1982657045
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 739
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:JANNIE
Authorized Official - Middle Name:DELANE
Authorized Official - Last Name:PASCHAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-429-4726
Mailing Address - Street 1:710 COUNTY ROAD 21 S
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334-9145
Mailing Address - Country:US
Mailing Address - Phone:320-634-4399
Mailing Address - Fax:320-634-4425
Practice Address - Street 1:710 COUNTY ROAD 21 S
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:MN
Practice Address - Zip Code:56334-9145
Practice Address - Country:US
Practice Address - Phone:320-634-4399
Practice Address - Fax:320-634-4425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN802967900Medicaid
MN911938000Medicaid
2423452OtherNCPDP
730000017Medicare PIN
2423452OtherNCPDP