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General NPI Number Information
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NPI Number | 1689673832
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Entity Type | Organization
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Legal Business Name | PRUETTS FOOD INC
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Dates
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Enumeration Date | 07/19/2005
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Last Update Date | 01/31/2021
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Provider Practice Location Address
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Address Line | 201 S PARK DR
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City | BROKEN BOW
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State | OK
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Zip | 74728-4737
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Country | US
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Telephone | 580-584-6085
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Fax | 580-584-6088
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Provider Business Mailing Address
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Address Line | 210 MAIN STREET
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City | BROKEN BOW
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State | OK
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Zip | 74728-4737
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Country | US
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Telephone | 580-584-6056
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Fax | 580-584-6088
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Authorized Official
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Title or Position | PHARMACY DIRECTOR
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Name | SHANNON JEWELANNA PRUETT
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Credential |
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Telephone | 580-584-6089
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 25-6949
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License Number State | OK
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