Provider Demographics
NPI:1366515694
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:BROOKSHIRE GROCERY COMPANY
Mailing Address - Street 2:PO BOX 1411
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 1:1010 AVENUE E
Practice Address - Street 2:ATTENTION PHARMACY DEPT
Practice Address - City:CISCO
Practice Address - State:TX
Practice Address - Zip Code:76437-3446
Practice Address - Country:US
Practice Address - Phone:254-442-2251
Practice Address - Fax:254-442-2251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
TX205653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX464713Medicaid
2094040OtherPK
2094040OtherPK
TXJ0117242OtherTX DPS
TX20565OtherTX STATE BOARD OF PHARMACY LICENSE
TX464713Medicaid
TXPH0342OtherMEDICARE IMMUNIZATION BILLING--TRAILBLAZER
BB6953283OtherDEA