Organization
PRUETTS FOOD INC
Active
Other names
PRUETT FOODS PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
SHANNON JEWELANNA PRUETT (PHARMACY DIRECTOR)
(580) 584-6089
Entity
Organization
Contact information
Practice address
201 S PARK DR, BROKEN BOW, OK 74728-4737
(580) 584-6085
(580) 584-6088
Mailing address
210 MAIN STREET, BROKEN BOW, OK 74728-4737
(580) 584-6056
(580) 584-6088
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
25-6949
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200019990A
—
OK
01
—
2076565
PK
—
Enumeration date
07/19/2005
Last updated
01/31/2021
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