Provider Demographics
NPI:1447397948
Name:NIEMANN FOODS INC
Entity Type:Organization
Organization Name:NIEMANN FOODS INC
Other - Org Name:COUNTY MARKET PHARMACY 392
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP / CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-221-5615
Mailing Address - Street 1:PO BOX C847
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62306-0847
Mailing Address - Country:US
Mailing Address - Phone:217-221-5641
Mailing Address - Fax:217-221-5929
Practice Address - Street 1:1555 W US HIGHWAY 54
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:MO
Practice Address - Zip Code:63382-1158
Practice Address - Country:US
Practice Address - Phone:573-594-2136
Practice Address - Fax:573-594-2744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130381723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2141913OtherPK
MO600280309Medicaid