Provider Demographics
NPI:1932353158
Name:PAMIDA STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:PAMIDA STORES OPERATING CO LLC
Other - Org Name:PAMIDA PHARMACY 696
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 1:998 US HWY 93 NORTH
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MT
Mailing Address - Zip Code:59917-9550
Mailing Address - Country:US
Mailing Address - Phone:406-297-3496
Mailing Address - Fax:406-297-7496
Practice Address - Street 1:998 US HWY 93 NORTH
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MT
Practice Address - Zip Code:59917-9550
Practice Address - Country:US
Practice Address - Phone:406-297-3496
Practice Address - Fax:406-297-7496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1273332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1932353158OtherMEDICAID DME
MT2783466OtherNCPDP
MT1273OtherLICENSE NUMBER
MT5694490157Medicare NSC