1699960286 NPI number — PAMIDA STORES OPERATING CO LLC

Table of content: (NPI 1699960286)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699960286 NPI number — PAMIDA STORES OPERATING CO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAMIDA STORES OPERATING CO LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PAMDIA PHARMACY 851
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699960286
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 S POLK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64402-1617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-831-0263
Provider Business Mailing Address Fax Number:
507-831-0263

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 S POLK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64402-1617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-831-0263
Provider Business Practice Location Address Fax Number:
507-831-0263
Provider Enumeration Date:
09/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROTHAMEL
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
SR VICE PRESIDENT
Authorized Official Telephone Number:
402-596-7499

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  2004017362 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2635540 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




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