1982656906 NPI number — SHOPKO STORES OPERATING CO. LLC

Table of content: (NPI 1982656906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982656906 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 OPTICAL 023
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:
1982656906
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 MAIN ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUTCHINSON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55350-1807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-587-4945
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 MAIN ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUTCHINSON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55350-1807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-587-4945
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/17/2006

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: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CP2230-20 . This is a "EYEMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 03092036203 . This is a "MN MA PRIMEWEST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 42609 . This is a "DAVIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 35720 . This is a "MN HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1C942SH . This is a "MN MA FIRST PLAN OF MN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1C943SH . This is a "MN MA FIRST PLAN OF MN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 014023 . This is a "VIP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 17823 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2100134 . This is a "MN MA MEDICA CHOICE CARE" identifier . This identifiers is of the category "OTHER".




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