Provider Demographics
NPI:1447323910
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 1:1600 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 1:2228 ISLAND BYU
Practice Address - Street 2:
Practice Address - City:BONHAM
Practice Address - State:TX
Practice Address - Zip Code:75418-2207
Practice Address - Country:US
Practice Address - Phone:903-583-2887
Practice Address - Fax:903-583-2122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX175023336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144540Medicaid
TX466125Medicaid
2106652OtherPK
1012120058Medicare NSC
BB5189748OtherDEA
DME00T118OtherTMHP MEDICARE CROSSOVER TO TX MEDICAID
TXJ0100751OtherTX DPS
TX466125Medicaid
TX17502OtherTX STATE BOARD OF PHARMACY LICENSE
TXPH0342OtherMEDICARE IMMUNIZATION BILLING--TRAILBLAZER