Provider Demographics
NPI:1619024767
Name:NIEMANN FOODS INC
Entity Type:Organization
Organization Name:NIEMANN FOODS INC
Other - Org Name:COUNTY MARKET PHARMACY 026
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:217-221-5612
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:217-221-5915
Practice Address - Street 1:825 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:IL
Practice Address - Zip Code:62363-1372
Practice Address - Country:US
Practice Address - Phone:217-285-5515
Practice Address - Fax:217-285-1326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
IL0540160653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1438200OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IL=========006Medicaid
1438200OtherNCPDP PROVIDER IDENTIFICATION NUMBER