Provider Demographics
NPI:1750562195
Name:PAMIDA STORES OPERATING CO LLC
Entity type:Organization
Organization Name:PAMIDA STORES OPERATING CO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-596-7206
Mailing Address - Street 1:113 WEST 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BEARDSTOWN
Mailing Address - State:IL
Mailing Address - Zip Code:62618
Mailing Address - Country:US
Mailing Address - Phone:217-323-4422
Mailing Address - Fax:217-323-4480
Practice Address - Street 1:113 WEST 3RD ST
Practice Address - Street 2:
Practice Address - City:BEARDSTOWN
Practice Address - State:IL
Practice Address - Zip Code:62618
Practice Address - Country:US
Practice Address - Phone:217-323-4422
Practice Address - Fax:217-323-4480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========005Medicaid
5694490138Medicare NSC