Provider Demographics
NPI:1710050042
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 CO
Mailing Address - Street 2:PO BOX 934
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:502C EAST GOODE
Practice Address - Street 2:ATTENTION PHARMACY DEPT
Practice Address - City:QUITMAN
Practice Address - State:TX
Practice Address - Zip Code:75783
Practice Address - Country:US
Practice Address - Phone:903-763-1420
Practice Address - Fax:903-763-3360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
TX214303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2097329OtherPK
TX465214Medicaid
1012120105Medicare NSC
TXA0122523OtherTX DPS
TXPH0342OtherMEDICARE IMMUNIZATION BILLING--TRAILBLAZER
TX21430OtherTX STATE BOARD OF PHARMACY LICENSE
TX465214Medicaid
4522187OtherOTHER ID NUMBER-COMMERCIAL NUMBER