=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669633491
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAMIDA STORES OPERATING CO., LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2008
-----------------------------------------------------
Last Update Date | 11/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 136 MCLEOD
-----------------------------------------------------
City | BIG TIMBER
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-932-5316
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 136 MCLEOD
-----------------------------------------------------
City | BIG TIMBER
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-932-5316
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT
-----------------------------------------------------
Name | MR. JOHN HARLOW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 402-596-7206
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 1268
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------