Healthcare Provider Details

I. General information

NPI: 1124065875
Provider Name (Legal Business Name): PAMIDA STORES OPERATING CO. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 04/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 S MAIN ST
CLINTONVILLE WI
54929-1565
US

IV. Provider business mailing address

8 S MAIN ST
CLINTONVILLE WI
54929-1565
US

V. Phone/Fax

Practice location:
  • Phone: 715-823-2106
  • Fax: 715-823-1322
Mailing address:
  • Phone: 715-823-2106
  • Fax: 715-823-1322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL E ROTHAMEL
Title or Position: CEO/PRESIDENT
Credential:
Phone: 402-596-7499