| Organization Name: | SHOPKO #602 |
| NPI Number: | 1265878110 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | NICK JACKSON (PHARMACY MANAGER) |
| Mailing Address: | 126 Charles St Oconto |
| State: | WI US |
| Postal Code: | 541539446 |
| Phone Number: | 9208345251 |
| Fax Number: | 9208349801 |
| NPI Enumeration Date: | 05/20/2013 |
| NPI Last Update Date: | 05/20/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 333600000X |
| License Number: | 900542 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Pharmacy |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A facility used by pharmacists for the compounding and dispensing of medicinal preparations and other associated professional and administrative services. A pharmacy is a facility whose primary function is to store, prepare and legally dispense prescription drugs under the professional supervision of a licensed pharmacist. It meets any licensing or certification standards set forth by the jurisdiction where it is located. |