Provider Demographics
NPI:1568562908
Name:BROOKSHIRE BROTHERS LTD
Entity Type:Organization
Organization Name:BROOKSHIRE BROTHERS LTD
Other - Org Name:BROOKSHIRE BROTHERS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RAYBURN
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHUM
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:936-634-8155
Mailing Address - Street 1:508 S VANBUREN
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75652
Mailing Address - Country:US
Mailing Address - Phone:903-657-3338
Mailing Address - Fax:903-657-2541
Practice Address - Street 1:508 S VANBUREN
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75652
Practice Address - Country:US
Practice Address - Phone:903-657-3338
Practice Address - Fax:903-657-2541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18294333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4591776OtherNCPDP
TX464094Medicaid
4591776OtherOTHER ID NUMBER-COMMERCIAL NUMBER
4591776OtherNCPDP