Organization
PRUETT'S FOOD, INC.
Active
Other names
PRUETT'S FOOD-PHARMACY#10
Organization subpart
No
Provider details
NPI number
Authorized official
SHANNON PRUETT (PHARMACY SUPERVISOR)
(580) 584-6056
Entity
Organization
Contact information
Practice address
1601 N BROADWAY AVE, ADA, OK 74820-1403
(580) 436-0900
(580) 332-2541
Mailing address
210 MAIN ST, BROKEN BOW, OK 74728-3976
(580) 584-6056
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
237926
OK
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200019990H
—
OK
01
—
2169412
PK
—
Enumeration date
06/14/2017
Last updated
11/28/2021
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