1699205575 NPI number — PRUETT'S FOOD, INC.

Table of content: (NPI 1699205575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699205575 NPI number — PRUETT'S FOOD, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRUETT'S FOOD, INC.
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:
Provider Other Organization Name Type Code:
6
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:
1699205575
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROKEN BOW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74728-3976
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-584-6056
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 N BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ADA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74820-1403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-436-0900
Provider Business Practice Location Address Fax Number:
580-332-2541
Provider Enumeration Date:
06/14/2017

Additional Information

Authorized Official

Authorized Official Last Name:
PRUETT
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY SUPERVISOR
Authorized Official Telephone Number:
580-584-6056

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  237926 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2169412 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200019990H , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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