Provider Demographics
NPI:1891741245
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
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 1:7401 MINERAL POINT RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1703
Mailing Address - Country:US
Mailing Address - Phone:608-833-6622
Mailing Address - Fax:608-833-2275
Practice Address - Street 1:7401 MINERAL POINT RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717
Practice Address - Country:US
Practice Address - Phone:608-833-6622
Practice Address - Fax:608-833-2275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332H00000X, 333600000X
WI85950423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5115262OtherNCPDP NUMBER
WI33025400Medicaid
0154160134Medicare ID - Type Unspecified
WI33025400Medicaid