Provider Demographics
NPI:1518300086
Name:BROOKSHIRE GROCERY COMPANY
Entity Type:Organization
Organization Name:BROOKSHIRE GROCERY COMPANY
Other - Org Name:BROOKSHIRE PHARMACY #88
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP PHARMACY OPS
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:COUSINEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-877-6829
Mailing Address - Street 1:PO BOX 1411
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75710-1411
Mailing Address - Country:US
Mailing Address - Phone:903-877-6827
Mailing Address - Fax:903-877-3820
Practice Address - Street 1:2300 W ENNIS AVE
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-8039
Practice Address - Country:US
Practice Address - Phone:972-875-4607
Practice Address - Fax:972-875-2060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-15
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX283773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139824OtherPK