Organization
SHOPKO STORES OPERATING CO LLC
Active
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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