1154350387 NPI number — SHOPKO STORES OPERATING CO LLC

Table of content: (NPI 1154350387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154350387 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 635
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:
1154350387
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
251 S 4TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61074-2123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-273-3581
Provider Business Mailing Address Fax Number:
815-273-3591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
251 S 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAVANNA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61074-2123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-273-3581
Provider Business Practice Location Address Fax Number:
815-273-3591
Provider Enumeration Date:
07/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BETTIGA
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE VICE PRESIDENT & COO
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: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0459230056 . This is a "MEDICARE ID - TYPE UNSPECIFIED" identifier . This identifiers is of the category "OTHER".