Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 2010
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RUSSELL STEINHORST (SVP AND CFO)
(920) 429-7489
Entity
Organization
Contact information
Practice address
1150 W WASHINGTON ST, MARQUETTE, MI 49855-4040
(906) 228-8380
(906) 228-3565
Mailing address
1150 W WASHINGTON ST, MARQUETTE, MI 49855-4040
(906) 228-8380
(906) 228-3565
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
3336C0003X
Community/Retail Pharmacy
Primary
5301008354
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2306909
NCPDP NUMBER
—
05
—
2306909
—
MI
01
—
4819069
MI MEDICAID DME
—
01
—
4913356
MI MEDICAID DME
—
01
—
9000E210860
BLUE CROSS PIN
MI
Enumeration date
05/10/2006
Last updated
12/15/2015
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