Provider Demographics
NPI:1770656241
Name:BROOKSHIRE GROCERY COMPANY
Entity Type:Organization
Organization Name:BROOKSHIRE GROCERY COMPANY
Other - Org Name:SUPER 1 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 1:1600 W SW LOOP 323
Mailing Address - Street 2:PO BOX 1411
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8532
Mailing Address - Country:US
Mailing Address - Phone:903-877-6827
Mailing Address - Fax:903-877-3820
Practice Address - Street 1:1870 AIRLINE DR
Practice Address - Street 2:ATTENTION PHARMACY DEPT
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-2702
Practice Address - Country:US
Practice Address - Phone:318-746-8401
Practice Address - Fax:318-746-8401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
LA32913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1263273Medicaid
2033530OtherPK
LA1263273Medicaid
BS4560466OtherDEA
LA1263273Medicaid
1770656241OtherNPI
LA1012120041Medicare NSC