Healthcare Provider Details

I. General information

NPI: 1821083809
Provider Name (Legal Business Name): PUCKETT FOOD STORES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N LOUIS TITTLE AVE
MANGUM OK
73554-4420
US

IV. Provider business mailing address

PO BOX 148
MANGUM OK
73554-0148
US

V. Phone/Fax

Practice location:
  • Phone: 580-782-2131
  • Fax: 580-782-9280
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number60-5307
License Number StateOK

VIII. Authorized Official

Name: VICTORIA L BROOKS
Title or Position: PHARMACY MANAGER
Credential: RPH
Phone: 580-782-2131