Provider Demographics
NPI:1932150372
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO PHARMACY 2123
Other - Org Type:Doing Business As
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 1:900 MEMORIAL RD
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:49931-2481
Mailing Address - Country:US
Mailing Address - Phone:906-487-9797
Mailing Address - Fax:906-487-9380
Practice Address - Street 1:900 MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:MI
Practice Address - Zip Code:49931-2481
Practice Address - Country:US
Practice Address - Phone:906-487-9797
Practice Address - Fax:906-487-9380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332H00000X
MI53010083623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
4819013OtherMI MEDICAID DME
MI2352451Medicaid
2352451OtherNCPDP NUMBER
MI9000C110300OtherBLUE CROSS PIN
4913392OtherMI MEDICAID DME
MI9000C110300OtherBLUE CROSS PIN
MI2352451Medicaid