Provider Demographics
NPI:1124191697
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 1:215 WEST WILLOW STREET
Mailing Address - Street 2:ATTENTION PHARMACY DEPT
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501
Mailing Address - Country:US
Mailing Address - Phone:318-572-9053
Mailing Address - Fax:318-572-9054
Practice Address - Street 1:215 W WILLOW ST
Practice Address - Street 2:ATTENTION PHARMACY DEPT
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-2841
Practice Address - Country:US
Practice Address - Phone:318-572-9053
Practice Address - Fax:318-572-9054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
LA41113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2033926OtherPK
LA1266485Medicaid
LA1266485Medicaid
BS6029450OtherDEA
LA1012120075Medicare NSC
LA004111OtherLA STATE BOARD OF PHARMACY LICENSE
LA1266485Medicaid