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NPI Code Detail

MEDICARE: SHOPKO STORES OPERATING COMPANY

MEDICARE: SHOPKO STORES OPERATING COMPANY
Medicare Provider Information

Scope of Practice

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

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometrist1643-035WI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1962452052
Entity Type Code : Organization
Provider Name (Legal Business Name) : SHOPKO STORES OPERATING COMPANY
Provider Business Mailing Address
First Line : 2430 E MASON ST
Second Line :
City : GREEN BAY
State : WI
Zip : 54302-3759
Country : US
Telephone Number : 920-468-4642
Fax Number : 920-468-3490
Provider Business Practice Location Address
First Line : 2430 E MASON ST
Second Line :
City : GREEN BAY
State : WI
Zip : 54302-3759
Country : US
Telephone Number : 920-468-4642
Fax Number : 920-468-3490
Authorized Official
Title or Position : OPTOMETRIST
Name : MR. JAMES L SCHMONSKY III
Credential : OD
Telephone Number : 920-468-4642
Provider Enumeration Date : 05/11/2006
Last Update Date : 08/22/2020

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Practice Location Address:
2430 E MASON ST
GREEN BAY, WI
54302-3759
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GREEN BAY, WI
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GREEN BAY, WI
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Directions to “SHOPKO STORES OPERATING COMPANY ” Practice Location

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