1407840366 NPI number — PRUETT'S CUT-RATE PHARMACY, LLC

Table of content: (NPI 1407840366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407840366 NPI number — PRUETT'S CUT-RATE PHARMACY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRUETT'S CUT-RATE PHARMACY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PRUETT'S CUT RATE PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407840366
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
744 S MISSISSIPPI AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATOKA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74525-3355
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-298-5064
Provider Business Mailing Address Fax Number:
580-298-6144

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
906 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANTLERS
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74523-2808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-298-5064
Provider Business Practice Location Address Fax Number:
580-298-6144
Provider Enumeration Date:
09/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
RITTER
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
580-889-0230

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 59-2947 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2074234 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100238490A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90003919743 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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