NPIMap

Organization Active NPI

Pruetts Food Inc

Doing business as Pruetts Food-Pharmacy#3

  • Community/Retail Pharmacy
  • De Queen, AR
National Provider Identifier
1659648285
Registry record updated Jan 31, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
AR14401 Issued in AR
Legal business name
PRUETTS FOOD INC
Doing business as
Pruetts Food-Pharmacy#3
Practice address
500 E Collin Raye Dr
De Queen, AR 71832-8048
Phone
(870) 642-5680
Fax
(870) 642-5683
NPI assigned
Nov 28, 2011
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 31, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Shannon Jewelanna PruettNPI 1033118286
Title
Pharmacy Director
Phone
(580) 584-6089

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X AR14401 AR Primary

Addresses

Primary practice location

500 E Collin Raye Dr
De Queen, AR 71832-8048

Mailing address

210 Main Street
Broken Bow, OK 74728-4737
Phone (870) 648-5680

Other identifiers 3

IdentifierTypeStateIssuer
20001990DMedicaidOK
2132858OtherPK
190021407AMedicaidAR

Other names 1

  • PRUETTS FOOD-PHARMACY#3 Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160809002724 AR Part B Supplier - Mass Immunization (Roster Biller Only) 9739157314 Practice locations: De Queen, AR

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Pruetts Food Inc7 organizations share this tax ID, including this one

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

Locations

500 E Collin Raye Dr
Ste 3
De Queen, AR 71832
Phone (870) 642-5680

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1322438400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1612051200000",
    "number": "1659648285",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "210 MAIN STREET",
            "city": "BROKEN BOW",
            "state": "OK",
            "postal_code": "747284737",
            "telephone_number": "870-648-5680",
            "fax_number": "870-648-5683"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "500 E COLLIN RAYE DR",
            "city": "DE QUEEN",
            "state": "AR",
            "postal_code": "718328048",
            "telephone_number": "870-642-5680",
            "fax_number": "870-642-5683"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRUETTS FOOD INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-11-28",
        "last_updated": "2021-01-31",
        "certification_date": "2021-01-31",
        "status": "A",
        "authorized_official_last_name": "PRUETT",
        "authorized_official_first_name": "SHANNON",
        "authorized_official_middle_name": "JEWELANNA",
        "authorized_official_title_or_position": "PHARMACY DIRECTOR",
        "authorized_official_telephone_number": "580-584-6089"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "AR",
            "license": "AR14401",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "20001990D",
            "state": "OK"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2132858",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "190021407A",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PRUETTS FOOD-PHARMACY#3",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PRUETTS FOOD-PHARMACY#3",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in De Queen, AR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 31, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.