1912933813 NPI number — SHOPKO STORES OPERATING CO LLC

Table of content: (NPI 1912933813)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912933813 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 145
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:
1912933813
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1190 N 6TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONMOUTH
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61462-9672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-734-7579
Provider Business Mailing Address Fax Number:
309-734-8111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1190 N 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONMOUTH
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61462-9672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-734-7579
Provider Business Practice Location Address Fax Number:
309-734-8111
Provider Enumeration Date:
06/23/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STEINHORST
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
Authorized Official Title or Position:
SVP CHIEF FINANCIAL OFFICER
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: 054015892 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1468695 . This is a "NCPDP NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 371110040145 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".