=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699447037
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROOKSTAN PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2021
-----------------------------------------------------
Last Update Date | 10/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1215 S COULTER ST STE 101
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79106-1761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-350-7451
-----------------------------------------------------
Fax | 806-350-7454
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1215 S COULTER ST STE 101
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79106-1761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-350-7451
-----------------------------------------------------
Fax | 806-350-7454
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/OWNER
-----------------------------------------------------
Name | BROOKE M MCLEAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 806-350-7451
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------