Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

8618042 Issued in WI

Legal business name

SHOPKO STORES OPERATING CO LLC

Doing business as

ShopKo Pharmacy 005

Practice address

230 N Wisconsin St
De Pere, WI 54115

Phone

(920) 336-2323

Fax

(920) 336-2186

NPI assigned

May 26, 2006

Last updated

Aug 24, 2018By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dilip Sedani

Title

VP

Phone

(920) 429-7688

Specialties & licenses 3

Addresses

Other identifiers 2

Other names 1

• ShopKo Pharmacy 005 Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1148601600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1535068800000",
    "number": "1285680637",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "230 N WISCONSIN ST",
            "city": "DE PERE",
            "state": "WI",
            "postal_code": "541152735",
            "telephone_number": "920-336-2323",
            "fax_number": "920-336-2186"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "230 N WISCONSIN ST",
            "city": "DE PERE",
            "state": "WI",
            "postal_code": "54115",
            "telephone_number": "920-336-2323",
            "fax_number": "920-336-2186"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-26",
        "last_updated": "2018-08-24",
        "status": "A",
        "authorized_official_last_name": "SEDANI",
        "authorized_official_first_name": "DILIP",
        "authorized_official_title_or_position": "VP",
        "authorized_official_telephone_number": "920-429-7688"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "WI",
            "license": "8618042",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "33058100",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "5117610",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Pharmacy 005",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "ShopKo Pharmacy 005",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Gregory Vincent Signorelli
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• Community/Retail Pharmacy in De Pere, WI
• Providers in De Pere, WI by specialty
• Community/Retail Pharmacy in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 24, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.