Provider Demographics
NPI:1518030840
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 1409
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:TX
Mailing Address - Zip Code:75758-1409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:703 HWY 31 EAST
Practice Address - Street 2:ATTENTION PHARMACY DEPT
Practice Address - City:CHANDLER
Practice Address - State:TX
Practice Address - Zip Code:75758
Practice Address - Country:US
Practice Address - Phone:903-849-4090
Practice Address - Fax:903-849-4129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
TX175143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX466126Medicaid
2106653OtherPK
TX144538Medicaid
1012120064Medicare NSC
TX17514OtherTX STATE BOARD OF PHARMACY LICENSE
1518030840OtherNPI
TX144538Medicaid
TXH0100897OtherTX DPS
BB5217600OtherDEA
TXPH0342OtherMEDICARE IMMUNIZATION BILLING--TRAILBLAZER