Provider Demographics
NPI:1558881623
Name:PRUETT'S FOOD, INC.
Entity Type:Organization
Organization Name:PRUETT'S FOOD, INC.
Other - Org Name:PRUETT'S FOOD-PHARMACY#9
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-236-2056
Mailing Address - Street 1:210 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-3976
Mailing Address - Country:US
Mailing Address - Phone:580-236-2056
Mailing Address - Fax:
Practice Address - Street 1:203 E HIGHWAY ST
Practice Address - Street 2:
Practice Address - City:HOLDENVILLE
Practice Address - State:OK
Practice Address - Zip Code:74848-4011
Practice Address - Country:US
Practice Address - Phone:405-379-6331
Practice Address - Fax:405-493-0697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-21
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK4079253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200019990FMedicaid
OK200019990FMedicaid