Healthcare Provider Details

I. General information

NPI: 1023272127
Provider Name (Legal Business Name): SHOPKO STORES OPERATING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 12/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15900 PICTURE BAY TRAIL
L'ANSE MI
49946-8125
US

IV. Provider business mailing address

15900 PICTURE BAY TRAIL
L'ANSE MI
49946-8125
US

V. Phone/Fax

Practice location:
  • Phone: 906-524-7032
  • Fax:
Mailing address:
  • Phone: 906-524-7032
  • Fax: 906-524-7020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. RUSSELL STEINHORST
Title or Position: EVP AND COO
Credential:
Phone: 920-429-7489