MEDICARE: PRUETT'S FOOD, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy
2	333600000X	Pharmacy	277924	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2169410	OTHER		PK

General Provider Information

NPI Number	:	1881124766
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRUETT'S FOOD, INC.

Provider Business Mailing Address
First Line	:	210 MAIN ST
Second Line	:
City	:	BROKEN BOW
State	:	OK
Zip	:	74728-3976
Country	:	US
Telephone Number	:	580-236-2056
Fax Number	:	580-584-6088

Provider Business Practice Location Address
First Line	:	1231 N WASHINGTON AVE
Second Line	:
City	:	DURANT
State	:	OK
Zip	:	74701-2119
Country	:	US
Telephone Number	:	580-924-2903
Fax Number	:	580-924-7337

Authorized Official
Title or Position	:	PHARMACY SUPERVISOR
Name	:	SHANNON PRUETT
Credential	:
Telephone Number	:	580-236-2056

Provider Enumeration Date	:	06/14/2017
Last Update Date	:	06/28/2020

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