Provider Demographics
NPI:1821083809
Name:PUCKETT FOOD STORES INC
Entity Type:Organization
Organization Name:PUCKETT FOOD STORES INC
Other - Org Name:PUCKETT DISCOUNT DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:580-782-2131
Mailing Address - Street 1:PO BOX 148
Mailing Address - Street 2:
Mailing Address - City:MANGUM
Mailing Address - State:OK
Mailing Address - Zip Code:73554-0148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 N LOUIS TITTLE AVE
Practice Address - Street 2:
Practice Address - City:MANGUM
Practice Address - State:OK
Practice Address - Zip Code:73554-4420
Practice Address - Country:US
Practice Address - Phone:580-782-2131
Practice Address - Fax:580-782-9280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK60-53073336C0003X
3336L0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2073882OtherPK
OK100235110BMedicaid
OK100235110BMedicaid