Provider Demographics
NPI:1780187021
Name:BROOKSHIRE GROCERY COMPANY
Entity Type:Organization
Organization Name:BROOKSHIRE GROCERY COMPANY
Other - Org Name:SUPER 1 PHARMACY #639
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR - PHARMACY OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:F
Authorized Official - Last Name:DUCOTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-534-3478
Mailing Address - Street 1:1600 WSW LOOP 323
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8532
Mailing Address - Country:US
Mailing Address - Phone:903-877-6514
Mailing Address - Fax:
Practice Address - Street 1:2004 N PARKERSON AVE
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-2336
Practice Address - Country:US
Practice Address - Phone:337-785-2421
Practice Address - Fax:337-785-2420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA006543333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy