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	License Number	License Number State
1	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1972846863
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOPKO STORES OPERATING CO LLC

Provider Business Mailing Address
First Line	:	211 S 23RD ST
Second Line	:
City	:	PLATTSMOUTH
State	:	NE
Zip	:	68048-2903
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	211 S 23RD ST
Second Line	:
City	:	PLATTSMOUTH
State	:	NE
Zip	:	68048-2903
Country	:	US
Telephone Number	:	402-296-5252
Fax Number	:

Authorized Official
Title or Position	:	SVP CHIEF FINANCIAL OFFICER
Name	:	RUSSELL STEINHORST
Credential	:
Telephone Number	:	920-429-7489

Provider Enumeration Date	:	03/29/2013
Last Update Date	:	03/08/2016

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