Healthcare Provider Details

I. General information

NPI: 1750562195
Provider Name (Legal Business Name): PAMIDA STORES OPERATING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 WEST 3RD ST
BEARDSTOWN IL
62618
US

IV. Provider business mailing address

113 WEST 3RD ST
BEARDSTOWN IL
62618
US

V. Phone/Fax

Practice location:
  • Phone: 217-323-4422
  • Fax: 217-323-4480
Mailing address:
  • Phone: 217-323-4422
  • Fax: 217-323-4480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN HARLOW
Title or Position: CEO/PRESIDENT
Credential:
Phone: 402-596-7206