Provider Demographics
NPI:1265878110
Name:SHOPKO #602
Entity type:Organization
Organization Name:SHOPKO #602
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-834-5251
Mailing Address - Street 1:126 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:OCONTO
Mailing Address - State:WI
Mailing Address - Zip Code:54153-9446
Mailing Address - Country:US
Mailing Address - Phone:920-834-5251
Mailing Address - Fax:920-834-9801
Practice Address - Street 1:126 CHARLES ST
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153-9446
Practice Address - Country:US
Practice Address - Phone:920-834-5251
Practice Address - Fax:920-834-9801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI900542333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy