NPIMap

Organization Active NPI

Pruett's Food, Inc.

Doing business as Pruett's Food-Pharmacy#10

  • Community/Retail Pharmacy
  • Ada, OK
National Provider Identifier
1699205575
Registry record updated Nov 28, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
Legal business name
PRUETT'S FOOD, INC.
Doing business as
Pruett's Food-Pharmacy#10
Practice address
1601 N Broadway Ave
Ada, OK 74820-1403
Phone
(580) 436-0900
Fax
(580) 332-2541
NPI assigned
Jun 14, 2017
Last updated
Nov 28, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 28, 2021

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

Authorized official

Name
Shannon Pruett
Title
Pharmacy Supervisor
Phone
(580) 584-6056

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X 237926 OK
Community/Retail Pharmacy 3336C0003X NU Primary

Addresses

Primary practice location

1601 N Broadway Ave
Ada, OK 74820-1403

Mailing address

210 Main St
Broken Bow, OK 74728-3976
Phone (580) 584-6056

Other identifiers 2

IdentifierTypeStateIssuer
2169412OtherPK
200019990HMedicaidOK

Other names 1

  • PRUETT'S FOOD-PHARMACY#10 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
This NPI is an additional NPI on the enrollment
Practice locations: Broken Bow, OK; Valliant, OK; McAlester, OK; Durant, OK; Holdenville, OK; Ada, OK

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.

NPI Registry JSON

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

{
    "created_epoch": "1497398400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1638057600000",
    "number": "1699205575",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "210 MAIN ST",
            "city": "BROKEN BOW",
            "state": "OK",
            "postal_code": "747283976",
            "telephone_number": "580-584-6056"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1601 N BROADWAY AVE",
            "city": "ADA",
            "state": "OK",
            "postal_code": "748201403",
            "telephone_number": "580-436-0900",
            "fax_number": "580-332-2541"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRUETT'S FOOD, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-06-14",
        "last_updated": "2021-11-28",
        "certification_date": "2021-11-28",
        "status": "A",
        "authorized_official_last_name": "PRUETT",
        "authorized_official_first_name": "SHANNON",
        "authorized_official_title_or_position": "PHARMACY SUPERVISOR",
        "authorized_official_telephone_number": "580-584-6056"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "OK",
            "license": "237926",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2169412",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200019990H",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PRUETT'S FOOD-PHARMACY#10",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Ada, OK

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 28, 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.