Healthcare Provider Details

I. General information

NPI: 1790736072
Provider Name (Legal Business Name): SHOPKO STORES OPERATING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2208 N WEBB RD
GRAND ISLAND NE
68803-1739
US

IV. Provider business mailing address

2208 N WEBB RD
GRAND ISLAND NE
68803-1739
US

V. Phone/Fax

Practice location:
  • Phone: 308-382-6744
  • Fax: 308-381-8401
Mailing address:
  • Phone: 308-382-6744
  • Fax: 308-381-8401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2676
License Number StateNE

VIII. Authorized Official

Name: MR. RUSSELL STEINHORST
Title or Position: SVP CHIEF FINANCIAL OFFICER
Credential:
Phone: 920-429-7489