Healthcare Provider Details

I. General information

NPI: 1881124766
Provider Name (Legal Business Name): PRUETT'S FOOD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 06/28/2020
Certification Date: 06/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1231 N WASHINGTON AVE
DURANT OK
74701-2119
US

IV. Provider business mailing address

210 MAIN ST
BROKEN BOW OK
74728-3976
US

V. Phone/Fax

Practice location:
  • Phone: 580-924-2903
  • Fax: 580-924-7337
Mailing address:
  • Phone: 580-236-2056
  • Fax: 580-584-6088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number277924
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SHANNON PRUETT
Title or Position: PHARMACY SUPERVISOR
Credential:
Phone: 580-236-2056