NPIMap

Organization Active NPI

Pruetts Food Inc

Doing business as Pruett Foods Pharmacy

  • Community/Retail Pharmacy
  • Broken Bow, OK
National Provider Identifier
1689673832
Registry record updated Jan 31, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
25-6949 Issued in OK
Legal business name
PRUETTS FOOD INC
Doing business as
Pruett Foods Pharmacy
Practice address
201 S Park Dr
Broken Bow, OK 74728-4737
Phone
(580) 584-6085
Fax
(580) 584-6088
NPI assigned
Jul 19, 2005
Last updated
Jan 31, 2021By the provider in NPPES
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 25-6949 OK Primary

Addresses

Primary practice location

201 S Park Dr
Broken Bow, OK 74728-4737

Mailing address

210 Main Street
Broken Bow, OK 74728-4737
Phone (580) 584-6056

Other identifiers 2

IdentifierTypeStateIssuer
200019990AMedicaidOK
2076565OtherPK

Other names 1

  • PRUETT FOODS PHARMACY Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040921001091 OK Part B Supplier - Mass Immunization (Roster Biller Only) 9739157314 5 other NPIs on this enrollment
Practice locations: Broken Bow, OK; Valliant, OK; McAlester, OK; Durant, OK; Holdenville, OK; Ada, OK

Other NPIs with the same Medicare PAC ID 1

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

Other NPIs on the same Medicare enrollment 5

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

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.

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": "1121731200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1612051200000",
    "number": "1689673832",
    "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": "580-584-6056",
            "fax_number": "580-584-6088"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "201 S PARK DR",
            "city": "BROKEN BOW",
            "state": "OK",
            "postal_code": "747284737",
            "telephone_number": "580-584-6085",
            "fax_number": "580-584-6088"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRUETTS FOOD INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-07-19",
        "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": "OK",
            "license": "25-6949",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200019990A",
            "state": "OK"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2076565",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PRUETT FOODS PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PRUETT FOODS PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Broken Bow, OK

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.