Provider Demographics
NPI:1679707095
Name:BROOKSHIRE GROCERY COMPANY
Entity type:Organization
Organization Name:BROOKSHIRE GROCERY COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:
Authorized Official - Last Name:DUCOTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-600-1376
Mailing Address - Street 1:420 S 145TH EAST AVE STE B
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74108-1305
Mailing Address - Country:US
Mailing Address - Phone:918-947-8180
Mailing Address - Fax:918-947-8199
Practice Address - Street 1:132 W TAFT AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-5433
Practice Address - Country:US
Practice Address - Phone:918-224-3600
Practice Address - Fax:918-224-3902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
OK11-54223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2120002OtherPK
OK100244350IMedicaid