Provider Demographics
NPI:1033118286
Name:PRUETT, SHANNON JEWELANNA (DPH)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:JEWELANNA
Last Name:PRUETT
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:692 OLD MILITARY ROAD
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-9659
Mailing Address - Country:US
Mailing Address - Phone:580-584-6089
Mailing Address - Fax:
Practice Address - Street 1:201 S PARK DR
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728-4737
Practice Address - Country:US
Practice Address - Phone:580-584-6085
Practice Address - Fax:580-584-6088
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2021-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12491183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist