Provider Demographics
NPI:1003869272
Name:PAMIDA STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:PAMIDA STORES OPERATING CO LLC
Other - Org Name:PAMIDA PHARMACY 335
Other - Org Type:Doing Business As
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 1:705 NORTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-2168
Mailing Address - Country:US
Mailing Address - Phone:763-389-3111
Mailing Address - Fax:763-389-1621
Practice Address - Street 1:705 NORTHLAND DR
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-2168
Practice Address - Country:US
Practice Address - Phone:763-389-3111
Practice Address - Fax:763-389-1621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MN262779-53336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN848647000Medicaid
MN510864100Medicaid
2420836OtherNCPDP
MN848647000Medicaid
MN510864100Medicaid
2420836OtherNCPDP