Provider Demographics
NPI:1023272127
Name:SHOPKO STORES OPERATING CO LLC
Entity type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EVP AND COO
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 1:15900 PICTURE BAY TRAIL
Mailing Address - Street 2:
Mailing Address - City:L'ANSE
Mailing Address - State:MI
Mailing Address - Zip Code:49946-8125
Mailing Address - Country:US
Mailing Address - Phone:906-524-7032
Mailing Address - Fax:906-524-7020
Practice Address - Street 1:15900 PICTURE BAY TRAIL
Practice Address - Street 2:
Practice Address - City:L'ANSE
Practice Address - State:MI
Practice Address - Zip Code:49946-8125
Practice Address - Country:US
Practice Address - Phone:906-524-7032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
5695760173Medicare NSC