Provider Demographics
NPI:1396796892
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:SVP AND CFO
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 1:2530 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-1390
Mailing Address - Country:US
Mailing Address - Phone:906-786-2011
Mailing Address - Fax:906-786-2816
Practice Address - Street 1:2530 1ST AVE N
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1390
Practice Address - Country:US
Practice Address - Phone:906-786-2011
Practice Address - Fax:906-786-2816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332H00000X
MI53010083603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
4819040OtherMI MEDICAID DME
4913383OtherMI MEDICAID DME
MI2341763Medicaid
MI9000B11041OtherBLUE CROSS PIN
2341763OtherNCPDP #
1111590049Medicare ID - Type Unspecified
MI9000B11041OtherBLUE CROSS PIN
MI2341763Medicaid