Provider Demographics
NPI:1689673832
Name:PRUETTS FOOD INC
Entity Type:Organization
Organization Name:PRUETTS FOOD INC
Other - Org Name:PRUETT FOODS PHARMACY
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:580-584-6089
Mailing Address - Street 1:210 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-4737
Mailing Address - Country:US
Mailing Address - Phone:580-584-6056
Mailing Address - Fax:580-584-6088
Practice Address - Street 1:201 S PARK DR
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728-4737
Practice Address - Country:US
Practice Address - Phone:580-584-6085
Practice Address - Fax:580-584-6088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2021-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK25-69493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200019990AMedicaid
2076565OtherPK
2076565OtherPK