Provider Demographics
NPI:1699205575
Name:PRUETT'S FOOD, INC.
Entity Type:Organization
Organization Name:PRUETT'S FOOD, INC.
Other - Org Name:PRUETT'S FOOD-PHARMACY#10
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:580-584-6056
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:580-584-6056
Mailing Address - Fax:
Practice Address - Street 1:1601 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-1403
Practice Address - Country:US
Practice Address - Phone:580-436-0900
Practice Address - Fax:580-332-2541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-14
Last Update Date:2021-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK237926333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2169412OtherPK
OK200019990HMedicaid