Provider Demographics
NPI:1093888562
Name:BROOKSHIRE GROCERY COMPANY
Entity Type:Organization
Organization Name:BROOKSHIRE GROCERY COMPANY
Other - Org Name:SUPER 1 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 1:1600 W SW LOOP 323
Mailing Address - Street 2:PO BOX 1411
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8532
Mailing Address - Country:US
Mailing Address - Phone:903-877-6827
Mailing Address - Fax:903-877-3820
Practice Address - Street 1:2610 RICHMOND RD
Practice Address - Street 2:ATTENTION PHARMACY DEPT
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2327
Practice Address - Country:US
Practice Address - Phone:903-832-2258
Practice Address - Fax:903-832-2451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
TX154623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2100929OtherPK
TX463944Medicaid
1012120063Medicare NSC
1093888562OtherNPI
TXDME00Q392OtherTMHP TEXAS MEDICAID DME FOR MEDICARE CROSSOVER CLAIMS
TX40084993OtherTX DPS
TX1012120063Medicare NSC
TX15462OtherTX STATE BOARD OF PHARMACY LICENSE
TX463944Medicaid