Healthcare Provider Details

I. General information

NPI: 1699841353
Provider Name (Legal Business Name): BROOKSHIRE GROCERY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S MUSKOGEE AVE
TAHLEQUAH OK
74464-5454
US

IV. Provider business mailing address

1600 WSW LOOP 323
TYLER TX
75701-8532
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-6103
  • Fax: 918-456-6118
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number36-5429
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100244350A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer
# 2
Identifier2073355
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

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