Provider Demographics
NPI:1437504669
Name:BROOKSIDERX LLC
Entity Type:Organization
Organization Name:BROOKSIDERX LLC
Other - Org Name:BROOKSIDERX LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC/MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:402-281-1957
Mailing Address - Street 1:11020 Q ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-3742
Mailing Address - Country:US
Mailing Address - Phone:402-374-4021
Mailing Address - Fax:402-403-4149
Practice Address - Street 1:11020 Q ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-3742
Practice Address - Country:US
Practice Address - Phone:402-374-4021
Practice Address - Fax:402-403-4149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-25
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NE6753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159748OtherPK