Provider Demographics
NPI:1699728253
Name:PAMIDA STORES OPERATING CO LLC
Entity type:Organization
Organization Name:PAMIDA STORES OPERATING CO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:5350 STATION DR
Mailing Address - Street 2:
Mailing Address - City:CALUMET
Mailing Address - State:MI
Mailing Address - Zip Code:49913-1853
Mailing Address - Country:US
Mailing Address - Phone:906-337-3597
Mailing Address - Fax:906-337-3695
Practice Address - Street 1:5350 STATION DR
Practice Address - Street 2:
Practice Address - City:CALUMET
Practice Address - State:MI
Practice Address - Zip Code:49913-1853
Practice Address - Country:US
Practice Address - Phone:906-337-3597
Practice Address - Fax:906-337-3695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MI53010083743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2354962Medicaid
2354962OtherNCPDP NUMBER
MI3192487Medicaid
MI4819167Medicaid
MI4913857Medicaid
MI4913857Medicaid
MI4819167Medicaid