MEDICARE: BROOKSHIRE GROCERY COMPANY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	24198	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2098266	OTHER		PK

General Provider Information

NPI Number	:	1376616847
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKSHIRE GROCERY COMPANY

Provider Business Mailing Address
First Line	:	1600 W SW LOOP 323
Second Line	:	PO BOX 1411
City	:	TYLER
State	:	TX
Zip	:	75701-8532
Country	:	US
Telephone Number	:	903-877-6827
Fax Number	:	903-877-3820

Provider Business Practice Location Address
First Line	:	590 W MAIN ST
Second Line	:	ATTENTION PHARMACY DEPT
City	:	HALLSVILLE
State	:	TX
Zip	:	75650-5189
Country	:	US
Telephone Number	:	903-668-1409
Fax Number	:	903-668-1320

Authorized Official
Title or Position	:	VP PHARMACY OPERATIONS
Name	:	JIM COUSINEAU
Credential	:	RPH
Telephone Number	:	903-877-6514

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	08/10/2016

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Directions to “BROOKSHIRE GROCERY COMPANY ” Practice Location

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