| Organization Name: | SHOPKO STORES OPERATING CO LLC |
| NPI Number: | 1326085077 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MICHAEL J BETTIGA (SR. VICE PRESIDENT HEALTH SERVICES) |
| Mailing Address: | 2655 Broadway Ave Boise |
| State: | ID US |
| Postal Code: | 837064721 |
| Phone Number: | 2083458728 |
| Fax Number: | 2083436591 |
| NPI Enumeration Date: | 06/01/2006 |
| NPI Last Update Date: | 07/25/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332B00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Durable Medical Equipment & Medical Supplies |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient |