Provider Demographics
NPI:1376554931
Name:TRUETT GUTHRIE
Entity Type:Organization
Organization Name:TRUETT GUTHRIE
Other - Org Name:BOOTHE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRUETT
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTHRIE
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:580-726-2221
Mailing Address - Street 1:100 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:OK
Mailing Address - Zip Code:73651-4010
Mailing Address - Country:US
Mailing Address - Phone:580-726-2221
Mailing Address - Fax:580-726-3530
Practice Address - Street 1:100 W 4TH ST
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:OK
Practice Address - Zip Code:73651-4010
Practice Address - Country:US
Practice Address - Phone:580-726-2221
Practice Address - Fax:580-726-3530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK41653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3705273OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OK100232150AMedicaid