Provider Demographics
NPI:1104461532
Name:PRUETT'S FOOD, INC.
Entity type:Organization
Organization Name:PRUETT'S FOOD, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-289-2085
Mailing Address - Street 1:210 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-3976
Mailing Address - Country:US
Mailing Address - Phone:870-289-2085
Mailing Address - Fax:580-584-6088
Practice Address - Street 1:101 W. MAIN
Practice Address - Street 2:
Practice Address - City:LOCKESBURG
Practice Address - State:AR
Practice Address - Zip Code:71846
Practice Address - Country:US
Practice Address - Phone:870-289-2085
Practice Address - Fax:870-289-2088
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRUETT'S FOOD, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-08
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR238810407Medicaid