Provider Demographics
NPI:1699960286
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:SR VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTHAMEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-596-7499
Mailing Address - Street 1:101 S POLK ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:MO
Mailing Address - Zip Code:64402-1617
Mailing Address - Country:US
Mailing Address - Phone:507-831-0263
Mailing Address - Fax:507-831-0263
Practice Address - Street 1:101 S POLK ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:MO
Practice Address - Zip Code:64402-1617
Practice Address - Country:US
Practice Address - Phone:507-831-0263
Practice Address - Fax:507-831-0263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004017362332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2635540OtherNCPDP
5694490070Medicare PIN
0459230128Medicare PIN