Provider Demographics
NPI:1730289182
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 1:1807 W FRANK AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1807 W FRANK AVE
Practice Address - Street 2:SUITE B
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3185
Practice Address - Country:US
Practice Address - Phone:936-634-3285
Practice Address - Fax:936-634-8218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX219903336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4525260OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TX350177Medicaid
4525260OtherNCPDP
0854980063Medicare NSC