Healthcare Provider Details

I. General information

NPI: 1124072921
Provider Name (Legal Business Name): SHOPKO STORES OPERATING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 N MONTANA AVE
HELENA MT
59602
US

IV. Provider business mailing address

3101 N MONTANA AVE
HELENA MT
59602-7813
US

V. Phone/Fax

Practice location:
  • Phone: 406-443-8823
  • Fax: 406-443-2282
Mailing address:
  • Phone: 406-443-8823
  • Fax: 406-443-2282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
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 Number1197
License Number StateMT

VIII. Authorized Official

Name: DILIP SEDANI
Title or Position: VP MANAGED HEALTH CARE
Credential:
Phone: 920-429-7688