Provider Demographics
NPI:1114308236
Name:BROOKSHIRE BROTHERS INC
Entity Type:Organization
Organization Name:BROOKSHIRE BROTHERS INC
Other - Org Name:BROOKSHIRE BROTHERS PHARMACY #109
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY OPERATIONS AND PERSON
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-634-8155
Mailing Address - Street 1:750 S HIGHWAY 377
Mailing Address - Street 2:
Mailing Address - City:PILOT POINT
Mailing Address - State:TX
Mailing Address - Zip Code:76258-4469
Mailing Address - Country:US
Mailing Address - Phone:940-686-5068
Mailing Address - Fax:940-686-5085
Practice Address - Street 1:750 S HIGHWAY 377
Practice Address - Street 2:
Practice Address - City:PILOT POINT
Practice Address - State:TX
Practice Address - Zip Code:76258-4469
Practice Address - Country:US
Practice Address - Phone:940-686-5068
Practice Address - Fax:940-686-5085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-15
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TX299913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152459OtherPK