Provider Demographics
NPI:1841558012
Name:NIEMANN FOODS INC
Entity Type:Organization
Organization Name:NIEMANN FOODS INC
Other - Org Name:COUNTY MARKET PHARMACY 458
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 847
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:217-221-5615
Mailing Address - Fax:217-221-5915
Practice Address - Street 1:518 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:IL
Practice Address - Zip Code:61542-1565
Practice Address - Country:US
Practice Address - Phone:309-547-3731
Practice Address - Fax:309-547-2040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540179623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134858OtherPK
IL=========013Medicaid