=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568356723
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN KYLE PRUITT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2025
-----------------------------------------------------
Last Update Date | 06/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 950 N WASHINGTON AVE
-----------------------------------------------------
City | COOKEVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38501-2666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-525-3649
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1701 RED BANKS RD
-----------------------------------------------------
City | BURKESVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42717-8771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-821-3498
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 48835
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------