1659322543 NPI number — SHOPKO STORES OPERATING CO LLC

Table of content: (NPI 1659322543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659322543 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 076
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:
1659322543
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 W 41ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57105-6371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-338-3155
Provider Business Mailing Address Fax Number:
605-334-4915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 W 41ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57105-6371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-338-3155
Provider Business Practice Location Address Fax Number:
605-334-4915
Provider Enumeration Date:
05/15/2006

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: 1001908 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 191318200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4304008 . This is a "NCPDP NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8503110 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9164950 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0722660 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9164952 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0966796 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8503112 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 886682000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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