1962449629 NPI number — BROOKSHIRE GROCERY COMPANY

Table of content: (NPI 1962449629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962449629 NPI number — BROOKSHIRE GROCERY COMPANY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOKSHIRE GROCERY COMPANY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
REASORS PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962449629
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 S 145TH EAST AVE STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74108-1305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-947-8180
Provider Business Mailing Address Fax Number:
918-947-8199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2429 E 15TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74104-4618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-748-8350
Provider Business Practice Location Address Fax Number:
918-747-1974
Provider Enumeration Date:
06/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DUCOTE
Authorized Official First Name:
NEIL
Authorized Official Middle Name:
Authorized Official Title or Position:
VP PHARMACY
Authorized Official Telephone Number:
903-600-1376

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2076242 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100244350F , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".