Provider Demographics
NPI:1558434886
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:BROOKSHIRE GROCERY COMPANY
Mailing Address - Street 2:PO BOX 1411
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75710-1411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 FM 3220
Practice Address - Street 2:ATTENTION PHARMACY DEPT
Practice Address - City:CLIFTON
Practice Address - State:TX
Practice Address - Zip Code:76634-1000
Practice Address - Country:US
Practice Address - Phone:254-675-3007
Practice Address - Fax:254-675-3008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
TX203533336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX464507Medicaid
2093498OtherPK
TX464507Medicaid
TX20353OtherTX STATE BOARD OF PHARMACY LICENSE
TX464507Medicaid
TXX0115441OtherTX DPS
TX1012120084Medicare NSC
4513479OtherOTHER ID NUMBER-COMMERCIAL NUMBER