1093766362 NPI number — SHOPKO STORES OPERATING CO LLC

Table of content: (NPI 1093766362)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093766362 NPI number — SHOPKO STORES OPERATING CO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHOPKO STORES OPERATING CO LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHOPKO PHARMACY 039
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093766362
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4200 S 27TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68502-5858
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-421-2444
Provider Business Mailing Address Fax Number:
402-421-1782

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4200 S 27TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68502-5858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-421-2444
Provider Business Practice Location Address Fax Number:
402-421-1782
Provider Enumeration Date:
05/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BETTIGA
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
SR. VICE PRESIDENT HEALTH SERVICES
Authorized Official Telephone Number:
920-429-4297

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 2677 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10025413700 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025074200 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2811140 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".