Healthcare Provider Details

I. General information

NPI: 1659648285
Provider Name (Legal Business Name): PRUETTS FOOD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 01/31/2021
Certification Date: 01/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E COLLIN RAYE DR
DE QUEEN AR
71832-8048
US

IV. Provider business mailing address

210 MAIN STREET
BROKEN BOW OK
74728-4737
US

V. Phone/Fax

Practice location:
  • Phone: 870-642-5680
  • Fax: 870-642-5683
Mailing address:
  • Phone: 870-648-5680
  • Fax: 870-648-5683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberAR14401
License Number StateAR

VIII. Authorized Official

Name: SHANNON JEWELANNA PRUETT
Title or Position: PHARMACY DIRECTOR
Credential:
Phone: 580-584-6089