Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 2643
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RUSSELL STEINHORST (SVP AND COO)
(920) 429-7489
Entity
Organization
Contact information
Practice address
91 PINE LAKE DR, NEWAYGO, MI 49337
(231) 652-9484
(231) 652-9485
Mailing address
91 PINE LAKE DR, NEWAYGO, MI 49337
(231) 652-9484
(231) 652-9485
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2361436
NCPDP NUMBER
—
05
—
2361436
—
MI
05
—
4819210
—
MI
05
—
4913875
—
MI
Enumeration date
05/19/2006
Last updated
12/14/2015
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