Provider Demographics
NPI:1083807697
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 1:1600 WSW LOOP 323
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11550 N 135TH EAST AVE
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-5739
Practice Address - Country:US
Practice Address - Phone:918-371-6455
Practice Address - Fax:918-371-6453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100244350HMedicaid
2077140OtherPK
OK100244350HMedicaid