Provider Demographics
NPI:1013080589
Name:BROOKSHIRE GROCERY COMPANY
Entity type:Organization
Organization Name:BROOKSHIRE GROCERY COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:PO BOX 1411
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75710-1411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1310 N BRAZOS ST
Practice Address - Street 2:ATTENTION PHARMACY DEPT
Practice Address - City:WHITNEY
Practice Address - State:TX
Practice Address - Zip Code:76692-2010
Practice Address - Country:US
Practice Address - Phone:254-694-4413
Practice Address - Fax:254-694-4418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
TX213463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2096740OtherPK
TX465112Medicaid
2096740OtherPK
TXPH0342OtherMEDICARE IMMUNIZATION BILLING--TRAILBLAZER
1012120092Medicare NSC
BB7570193OtherDEA
TXA0122242OtherTX DPS
TX465112Medicaid