Provider Demographics
NPI:1407840366
Name:PRUETT'S CUT-RATE PHARMACY, LLC
Entity Type:Organization
Organization Name:PRUETT'S CUT-RATE PHARMACY, LLC
Other - Org Name:PRUETT'S CUT RATE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RITTER
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:580-889-0230
Mailing Address - Street 1:744 S MISSISSIPPI AVE
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-3355
Mailing Address - Country:US
Mailing Address - Phone:580-298-5064
Mailing Address - Fax:580-298-6144
Practice Address - Street 1:906 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ANTLERS
Practice Address - State:OK
Practice Address - Zip Code:74523-2808
Practice Address - Country:US
Practice Address - Phone:580-298-5064
Practice Address - Fax:580-298-6144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X
OK59-29473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2074234OtherPK
OK100238490AMedicaid
OK90003919743Medicaid
OK90003919743Medicaid