Provider Demographics
NPI:1124072921
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:VP MANAGED HEALTH CARE
Authorized Official - Prefix:
Authorized Official - First Name:DILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:SEDANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-429-7688
Mailing Address - Street 1:3101 N MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59602-7813
Mailing Address - Country:US
Mailing Address - Phone:406-443-8823
Mailing Address - Fax:406-443-2282
Practice Address - Street 1:3101 N MONTANA AVE
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59602
Practice Address - Country:US
Practice Address - Phone:406-443-8823
Practice Address - Fax:406-443-2282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332H00000X, 332B00000X
MT11973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332H00000XSuppliersEyewear Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT5607331Medicaid
MT0213577Medicaid
MT0230435Medicaid
MT5607909Medicaid
2705018OtherNCPDP NUMBER
0154160205Medicare ID - Type Unspecified
MT5607331Medicaid
MT0230435Medicaid