Provider Demographics
NPI:1396818621
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 1:1310 SOUTH CONSTITUTION AVE
Mailing Address - Street 2:ATTENTION PHARMACY DEPT
Mailing Address - City:ASHDOWN
Mailing Address - State:AR
Mailing Address - Zip Code:71822
Mailing Address - Country:US
Mailing Address - Phone:870-898-5501
Mailing Address - Fax:870-898-5594
Practice Address - Street 1:1310 S CONSTITUTION AVE
Practice Address - Street 2:ATTENTION PHARMACY DEPT
Practice Address - City:ASHDOWN
Practice Address - State:AR
Practice Address - Zip Code:71822-8652
Practice Address - Country:US
Practice Address - Phone:870-898-5501
Practice Address - Fax:870-898-5594
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
ARAR202913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1989424OtherPK
AR145333407Medicaid
AR145333407Medicaid
BB7542625OtherDEA
AR10662OtherMEDICARE IMMUNIZATION BILLING--PINNACLE BSI
ARAR20291OtherAR STATE BOARD OF PHARMACY LICENSE
AR1012120090Medicare NSC