Provider Demographics
NPI:1285707752
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:D
Authorized Official - Last Name:COUSINEAU
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-877-6829
Mailing Address - Street 1:PO BOX 1411
Mailing Address - Street 2:ATTN PHCY DEPT
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75710-1411
Mailing Address - Country:US
Mailing Address - Phone:903-962-4063
Mailing Address - Fax:903-877-3820
Practice Address - Street 1:205 W FRANK ST
Practice Address - Street 2:ATTENTION PHARMACY DEPT
Practice Address - City:GRAND SALINE
Practice Address - State:TX
Practice Address - Zip Code:75140-1757
Practice Address - Country:US
Practice Address - Phone:903-962-4063
Practice Address - Fax:903-962-4253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TX251273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX25127OtherTX STATE BOARD OF PHARMACY LICENSE
TXPH0342OtherMEDICARE IMMUNIZATION BILLING--TRAILBLAZER
TX145708Medicaid
1285707752OtherNPI
TXR0148456OtherTX DPS
4542608OtherOTHER ID NUMBER-COMMERCIAL NUMBER
4542608OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TXR0148456OtherTX DPS