Basic Information
| Provider Information | |||||||||
| NPI: | 1194756296 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRUETT MEDICAL, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 21445 | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767021445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547720040 | ||||||||
| FaxNumber: | 2547721110 | ||||||||
| Practice Location | |||||||||
| Address1: | 6813 CACTUS | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767126160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547720040 | ||||||||
| FaxNumber: | 2547721110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PRUETT | ||||||||
| AuthorizedOfficialFirstName: | ANNE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/C.O.B. | ||||||||
| AuthorizedOfficialTelephone: | 2547720040 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BN1400X | 0034661 | TX | X | Suppliers | Durable Medical Equipment & Medical Supplies | Nursing Facility Supplies | 332BP3500X | 0034661 | TX | X | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition |
ID Information
| ID | Type | State | Issuer | Description | 0000508611 | 01 | BLUE CROSS BLUE SHIELD TX | OTHER | J09900025015 | 01 | SIERRA HEALTH AND LIFE | OTHER | 0005231045 | 01 | AETNA | OTHER |