Shopko Stores Operating Co LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

Legal business name

SHOPKO STORES OPERATING CO LLC

Practice address

56419 Pokagon St
Dowagiac, MI 49047-7721

Phone

(269) 782-0280

Fax

(269) 782-0282

NPI assigned

May 17, 2006

Organization subpart

No

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

Authorized official

Name

Mr. Russell Steinhorst

Title

SVP and Coo

Phone

(920) 429-7489

Specialties & licenses 3

Addresses

Other identifiers 5

Other names 1

• Shopko Pharmacy 2650 Doing business as

Locations

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

{
    "created_epoch": "1147824000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1450137600000",
    "number": "1427001056",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "56419 POKAGON ST",
            "city": "DOWAGIAC",
            "state": "MI",
            "postal_code": "490477721",
            "telephone_number": "269-782-0280",
            "fax_number": "269-782-0282"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "56419 POKAGON ST",
            "city": "DOWAGIAC",
            "state": "MI",
            "postal_code": "490477721",
            "telephone_number": "269-782-0280",
            "fax_number": "269-782-0282"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-17",
        "last_updated": "2015-12-15",
        "status": "A",
        "authorized_official_last_name": "STEINHORST",
        "authorized_official_first_name": "RUSSELL",
        "authorized_official_title_or_position": "SVP AND COO",
        "authorized_official_telephone_number": "920-429-7489",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "540A410170",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4913436",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP NUMBER",
            "identifier": "2367096",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2367096",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4819274",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shopko Pharmacy 2650",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• All providers in Dowagiac, MI
• Community/Retail Pharmacy in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 15, 2015; 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.