Puckett Food Stores Inc

Key facts

NPI

1821083809

Entity type

Organization (NPI type 2)

Primary specialty

Community/Retail Pharmacy 3336C0003X

License

60-5307 (OK)

Legal business name

PUCKETT FOOD STORES INC

Practice address

101 N Louis Tittle Ave
Mangum, OK 73554-4420

Phone

(580) 782-2131

Fax

(580) 782-9280

NPI assigned

Sep 15, 2005

Organization subpart

No

Authorized official

Name

Victoria L Brooks, RPH

Title

Pharmacy Manager

Phone

(580) 782-2131

National Provider Directory

Locations

Specialties & licenses

Addresses

Other identifiers

Other names

• PUCKETT DISCOUNT DRUG Doing business as

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Dec 16, 2019.

{
    "created_epoch": "1126742400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1576454400000",
    "number": "1821083809",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 148",
            "city": "MANGUM",
            "state": "OK",
            "postal_code": "735540148"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "101 N LOUIS TITTLE AVE",
            "city": "MANGUM",
            "state": "OK",
            "postal_code": "735544420",
            "telephone_number": "580-782-2131",
            "fax_number": "580-782-9280"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PUCKETT FOOD STORES INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-09-15",
        "last_updated": "2019-12-16",
        "certification_date": "2019-12-16",
        "status": "A",
        "authorized_official_last_name": "BROOKS",
        "authorized_official_first_name": "VICTORIA",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "PHARMACY MANAGER",
        "authorized_official_telephone_number": "580-782-2131",
        "authorized_official_credential": "RPH"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "OK",
            "license": "60-5307",
            "primary": true
        },
        {
            "code": "3336L0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Long Term Care Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2073882",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100235110B",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PUCKETT DISCOUNT DRUG",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PUCKETT DISCOUNT DRUG",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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