Provider Demographics
NPI:1508939075
Name:BROOKSHIRE GROCERY COMPANY
Entity Type:Organization
Organization Name:BROOKSHIRE GROCERY COMPANY
Other - Org Name:SUPER 1 FOODS 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 1:1605 EAST HARDING AVENUE
Mailing Address - Street 2:ATTENTION PHARMACY DEPT
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71601
Mailing Address - Country:US
Mailing Address - Phone:870-534-1380
Mailing Address - Fax:870-534-1681
Practice Address - Street 1:1605 E HARDING AVE
Practice Address - Street 2:ATTENTION PHARMACY DEPT
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71601-6823
Practice Address - Country:US
Practice Address - Phone:870-534-1380
Practice Address - Fax:870-534-1681
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
AR04200063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR130900407Medicaid
1988191OtherPK
AR130900407Medicaid
ARAR20006OtherAR STATE BOARD OF PHARMACY LICENSE
AR130900407Medicaid
AR10662OtherMEDICARE IMMUNIZATION BILLING--PINNACLE BSI
BB5255876OtherDEA