Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 2011
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RUSSELL STEINHORST (SVP AND CFO)
(920) 429-7489
Entity
Organization
Contact information
Practice address
500 S CARPENTER AVE, KINGSFORD, MI 49802-4529
(906) 774-7907
(906) 774-5547
Mailing address
500 S CARPENTER AVE, KINGSFORD, MI 49802-4529
(906) 774-7907
(906) 774-5547
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
5301008363
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2321418
NCPDP NUMBER
—
05
—
2321418
—
MI
05
—
33127600
—
WI
01
—
4819031
MI MEDICAID DME
—
01
—
4913374
MI MEDICAID DME
—
01
—
9000B210480
BLUE CROSS PIN
MI
Enumeration date
05/09/2006
Last updated
12/14/2015
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