1104875731 NPI number — SHOPKO STORES OPERATING CO LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104875731 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 2010
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:
1104875731
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1150 W WASHINGTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARQUETTE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49855-4040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-228-8380
Provider Business Mailing Address Fax Number:
906-228-3565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1150 W WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARQUETTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49855-4040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-228-8380
Provider Business Practice Location Address Fax Number:
906-228-3565
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STEINHORST
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
Authorized Official Title or Position:
SVP AND CFO
Authorized Official Telephone Number:
920-429-7489

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: 5301008354 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2306909 . This is a "NCPDP NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9000E210860 . This is a "BLUE CROSS PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2306909 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4913356 . This is a "MI MEDICAID DME" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4819069 . This is a "MI MEDICAID DME" identifier . This identifiers is of the category "OTHER".




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