1497794374 NPI number — SHOPKO STORES OPERATING CO LLC

Table of content: (NPI 1497794374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497794374 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:
Provider Other Organization Name Type Code:
6
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:
1497794374
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 BOYD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWCASTLE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82701-2965
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-746-2741
Provider Business Mailing Address Fax Number:
307-746-9405

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 BOYD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWCASTLE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82701-2965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-746-2741
Provider Business Practice Location Address Fax Number:
307-746-9405
Provider Enumeration Date:
06/06/2006

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: 102724700 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 123288601 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 123288600 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5202572 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8530192 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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