Provider Demographics
NPI:1396818860
Name:BROOKSHIRE GROCERY COMPANY
Entity Type:Organization
Organization Name:BROOKSHIRE GROCERY COMPANY
Other - Org Name:BROOKSHIRES PHARMACY #121
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:D
Authorized Official - Last Name:COUSINEAU
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-877-6829
Mailing Address - Street 1:PO BOX 1411
Mailing Address - Street 2:ATTENTION PHARMACY DEPT
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75710-1411
Mailing Address - Country:US
Mailing Address - Phone:601-978-1747
Mailing Address - Fax:903-877-6909
Practice Address - Street 1:5841 RIDGEWOOD RD
Practice Address - Street 2:ATTENTION PHARMACY DEPT
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-2618
Practice Address - Country:US
Practice Address - Phone:601-978-1747
Practice Address - Fax:601-978-3150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
MS05104 / 01.2333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2521107OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MS0330682Medicaid
MS0330682Medicaid