Provider Demographics
NPI:1881019826
Name:BROOKSTAN PHARMACY LLC
Entity Type:Organization
Organization Name:BROOKSTAN PHARMACY LLC
Other - Org Name:MEDICAL SQUARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER, PIC
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-350-7451
Mailing Address - Street 1:1215 S COULTER ST STE 101
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1761
Mailing Address - Country:US
Mailing Address - Phone:806-350-7451
Mailing Address - Fax:806-350-7454
Practice Address - Street 1:1215 S COULTER ST STE 101
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1761
Practice Address - Country:US
Practice Address - Phone:806-350-7451
Practice Address - Fax:806-350-7454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-27
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X, 3336L0003X
TX295203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147014Medicaid
2147909OtherPK