1821083809 NPI number — PUCKETT FOOD STORES INC

Table of content: (NPI 1821083809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821083809 NPI number — PUCKETT FOOD STORES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUCKETT FOOD STORES 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:
1821083809
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 148
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANGUM
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73554-0148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 N LOUIS TITTLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANGUM
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73554-4420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-782-2131
Provider Business Practice Location Address Fax Number:
580-782-9280
Provider Enumeration Date:
09/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BROOKS
Authorized Official First Name:
VICTORIA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
580-782-2131

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  60-5307 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2073882 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100235110B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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