Provider Demographics
NPI:1003182122
Name:BROOKSHIRE GROCERY COMPANY
Entity Type:Organization
Organization Name:BROOKSHIRE GROCERY COMPANY
Other - Org Name:SUPER ONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP PHARMACY OPS
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:COUSINEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-877-6829
Mailing Address - Street 1:3916 NE EVANGELINE THRUWAY
Mailing Address - Street 2:
Mailing Address - City:CARENCRO
Mailing Address - State:LA
Mailing Address - Zip Code:70520
Mailing Address - Country:US
Mailing Address - Phone:337-886-3660
Mailing Address - Fax:337-886-3661
Practice Address - Street 1:3916 NE EVANGELINE TRWY
Practice Address - Street 2:
Practice Address - City:CARENCRO
Practice Address - State:LA
Practice Address - Zip Code:70520-5972
Practice Address - Country:US
Practice Address - Phone:337-886-3660
Practice Address - Fax:337-886-3661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-23
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPHY.006495-RC3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134197OtherPK
LA006495OtherSTATE
=========OtherTAX PAYER ID
LAFB3095393OtherDEA