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Provider Information for 1912398736


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SHOPKO STORES OPERATING CO., LLC

Other Names:  
Doing Business As: 
SHOPKO PHARMACY 795

Organization Subpart: NO

NPI: 1912398736
Last Updated: 2015-07-07
Certification Date:

Details

NameValue
NPI1912398736
Enumeration Date2015-02-16
NPI TypeNPI-2 Organization
StatusActive
Authorized Official Information Name: LORIE NEUMANN
Title: Dir 3d Party Contract & CA
Phone: 9204294726
Mailing Address 1026 S CHALLIS ST
SALMON, ID 83467-5441
United States

Phone: 208-742-1285 | Fax:208-742-1283
 
Primary Practice Address 1026 S CHALLIS ST
SALMON, ID 83467-5441
United States

Phone: 208-742-1285 | Fax:208-742-1283
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
MEDICAIDID1912398736
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
No 332B00000X - Durable Medical Equipment & Medical Supplies
No 333600000X - Pharmacy
Yes 3336C0003X - Pharmacy - Community/Retail Pharmacy