Provider Demographics
NPI:1629669007
Name:PRUETT, SHERRILL
Entity Type:Individual
Prefix:
First Name:SHERRILL
Middle Name:
Last Name:PRUETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 E LOMA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-4220
Mailing Address - Country:US
Mailing Address - Phone:361-652-9858
Mailing Address - Fax:
Practice Address - Street 1:6106 N NAVARRO ST
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-1769
Practice Address - Country:US
Practice Address - Phone:361-572-8575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX297209183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician