Healthcare Provider Details

I. General information

NPI: 1194076216
Provider Name (Legal Business Name): BROOKSHIRE GROCERY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2012
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11116 S MEMORIAL DR
BIXBY OK
74008-2038
US

IV. Provider business mailing address

1600 WSW LOOP 323
TYLER TX
75701-8532
US

V. Phone/Fax

Practice location:
  • Phone: 918-970-4919
  • Fax: 918-970-2790
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: NEIL DUCOTE
Title or Position: VP PHARMACY
Credential:
Phone: 903-600-1376