MEDICARE: SHOPKO STORES OPERATING CO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	2355661	OTHER	NCPDP NUMBER
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134172794
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOPKO STORES OPERATING CO LLC

Provider Business Mailing Address
First Line	:	174 JAMES ROBERTSON DR
Second Line	:
City	:	GLADWIN
State	:	MI
Zip	:	48624-7006
Country	:	US
Telephone Number	:	989-426-7020
Fax Number	:	989-426-7155

Provider Business Practice Location Address
First Line	:	174 JAMES ROBERTSON DR
Second Line	:
City	:	GLADWIN
State	:	MI
Zip	:	48624-7006
Country	:	US
Telephone Number	:	989-426-7020
Fax Number	:	989-426-7155

Authorized Official
Title or Position	:	SVP AND COO
Name	:	MR. RUSSELL STEINHORST
Credential	:
Telephone Number	:	920-429-7489

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	12/14/2015

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Directions to “SHOPKO STORES OPERATING CO LLC ” Practice Location

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