Provider Demographics
NPI:1194756296
Name:PRUETT MEDICAL, INC.
Entity type:Organization
Organization Name:PRUETT MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/C.O.B.
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:C
Authorized Official - Last Name:PRUETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-772-0040
Mailing Address - Street 1:PO BOX 21445
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76702-1445
Mailing Address - Country:US
Mailing Address - Phone:254-772-0040
Mailing Address - Fax:254-772-1110
Practice Address - Street 1:6813 CACTUS
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-6160
Practice Address - Country:US
Practice Address - Phone:254-772-0040
Practice Address - Fax:254-772-1110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0034661332BN1400X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
Not Answered332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000508611OtherBLUE CROSS BLUE SHIELD TX
J09900025015OtherSIERRA HEALTH AND LIFE
0005231045OtherAETNA
J09900025015OtherSIERRA HEALTH AND LIFE
0=========OtherCHRISTIAN FIDELITY
=========OtherAMERICAN REPUBLIC