Provider Demographics
NPI:1275606501
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:PO BOX 1219
Mailing Address - Street 2:ATTENTION PHARMACY DEPT
Mailing Address - City:VAN
Mailing Address - State:TX
Mailing Address - Zip Code:75790-1219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:706 WEST MAIN
Practice Address - Street 2:ATTENTION PHARMACY DEPT
Practice Address - City:VAN
Practice Address - State:TX
Practice Address - Zip Code:75790
Practice Address - Country:US
Practice Address - Phone:903-963-3834
Practice Address - Fax:903-963-3534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX209933336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX464885Medicaid
2095837OtherPK
TX464885Medicaid
4519039OtherOTHER ID NUMBER-COMMERCIAL NUMBER
40120391OtherTX DPS
1275606501OtherNPI
TX20993OtherTX BOARD OF PHARM LICENSE
TX464885Medicaid