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General NPI Number Information
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NPI Number | 1962452052
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Entity Type | Organization
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Legal Business Name | SHOPKO STORES OPERATING COMPANY
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Dates
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Enumeration Date | 05/11/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2430 E MASON ST
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City | GREEN BAY
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State | WI
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Zip | 54302-3759
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Country | US
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Telephone | 920-468-4642
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Fax | 920-468-3490
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Provider Business Mailing Address
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Address Line | 2430 E MASON ST
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City | GREEN BAY
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State | WI
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Zip | 54302-3759
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Country | US
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Telephone | 920-468-4642
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Fax | 920-468-3490
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | MR. JAMES L SCHMONSKY III
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Credential | OD
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Telephone | 920-468-4642
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1643-035
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License Number State | WI
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