Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
ShopKo Pharmacy 2123
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RUSSELL STEINHORST (SVP AND CFO)
(920) 429-7489
Entity
Organization
Contact information
Practice address
900 MEMORIAL RD, HOUGHTON, MI 49931-2481
(906) 487-9797
(906) 487-9380
Mailing address
900 MEMORIAL RD, HOUGHTON, MI 49931-2481
(906) 487-9797
(906) 487-9380
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332H00000X
Eyewear Supplier
—
—
3336C0003X
Community/Retail Pharmacy
Primary
5301008362
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2352451
NCPDP NUMBER
—
05
—
2352451
—
MI
01
—
4819013
MI MEDICAID DME
—
01
—
4913392
MI MEDICAID DME
—
01
—
9000C110300
BLUE CROSS PIN
MI
Enumeration date
05/12/2006
Last updated
08/03/2016
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