Provider Demographics
NPI:1104875731
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 1:1150 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4040
Mailing Address - Country:US
Mailing Address - Phone:906-228-8380
Mailing Address - Fax:906-228-3565
Practice Address - Street 1:1150 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4040
Practice Address - Country:US
Practice Address - Phone:906-228-8380
Practice Address - Fax:906-228-3565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332H00000X
MI53010083543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
2306909OtherNCPDP NUMBER
MI9000E210860OtherBLUE CROSS PIN
MI2306909Medicaid
4913356OtherMI MEDICAID DME
4819069OtherMI MEDICAID DME
MI9000E210860OtherBLUE CROSS PIN
5695760077Medicare NSC