Provider Demographics
NPI:1053484386
Name:BROOKSHIRE GROCERY COMPANY
Entity Type:Organization
Organization Name:BROOKSHIRE GROCERY COMPANY
Other - Org Name:BROOKSHIRES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP PHARMACY OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:COUSINEAU
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-877-6514
Mailing Address - Street 1:2800 PINE STREET NO 5 PINE PLAZA
Mailing Address - Street 2:ATTENTION PHARMACY DEPT
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923
Mailing Address - Country:US
Mailing Address - Phone:870-246-2015
Mailing Address - Fax:870-246-2915
Practice Address - Street 1:2800 PINE ST
Practice Address - Street 2:ATTENTION PHARMACY DEPT
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-5321
Practice Address - Country:US
Practice Address - Phone:870-246-2015
Practice Address - Fax:870-246-2915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
AR04200033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1988194OtherPK
AR130897407Medicaid
AR130897407Medicaid
ARAR20003OtherAR STATE BOARD OF PHARMACY LICENSE
0419817OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1053484386OtherNPI
AR10662OtherMEDICARE IMMUNIZATION BILLING--PINNACLE BSI