1689835647 NPI number — SHOPKO STORES OPERATING CO LLC

Table of content: (NPI 1689835647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689835647 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 179
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:
1689835647
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5630 ST CROIX TRAIL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH BRANCH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-674-9951
Provider Business Mailing Address Fax Number:
651-674-9907

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5630 ST CROIX TRAIL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH BRANCH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-674-9951
Provider Business Practice Location Address Fax Number:
651-674-9907
Provider Enumeration Date:
06/23/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BETTIGA
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
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: 1689835647 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".