=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326114083
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROOKSHIRE GROCERY COMPANY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2006
-----------------------------------------------------
Last Update Date | 04/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 W WILL ROGERS BLVD
-----------------------------------------------------
City | CLAREMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74017-5419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-341-4557
-----------------------------------------------------
Fax | 918-343-8735
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 WSW LOOP 323
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75701-8532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP PHARMACY
-----------------------------------------------------
Name | NEIL DUCOTE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 903-600-1376
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------