Provider Demographics
NPI:1629669874
Name:PRUETT'S FOOD, INC.
Entity Type:Organization
Organization Name:PRUETT'S FOOD, INC.
Other - Org Name:UPTOWN PHARMACY (PRUETT'S OKC)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:JEWELANNA
Authorized Official - Last Name:PRUETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-236-2056
Mailing Address - Street 1:210 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9515 N MAY AVE
Practice Address - Street 2:
Practice Address - City:THE VILLAGE
Practice Address - State:OK
Practice Address - Zip Code:73120
Practice Address - Country:US
Practice Address - Phone:405-286-9080
Practice Address - Fax:405-286-9832
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRUETT'S FOOD, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-01-31
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200019990JMedicaid