Provider Demographics
NPI:1891944187
Name:PAMIDA STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:PAMIDA STORES OPERATING CO LLC
Other - Org Name:PAMIDA PHARMACY 697
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 1:100 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIGOURNEY
Mailing Address - State:IA
Mailing Address - Zip Code:52591-1414
Mailing Address - Country:US
Mailing Address - Phone:641-622-3184
Mailing Address - Fax:641-622-1054
Practice Address - Street 1:100 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SIGOURNEY
Practice Address - State:IA
Practice Address - Zip Code:52591-1414
Practice Address - Country:US
Practice Address - Phone:641-622-3184
Practice Address - Fax:641-622-1054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-11
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA79332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1891944187Medicaid
1623506OtherNCPDP
1623506OtherNCPDP