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	932939	LA

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	2033200	OTHER		PK

General Provider Information

NPI Number	:	1780757252
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	:	2640 WAGGONER AVE
Second Line	:	ATTENTION PHARMACY DEPT
City	:	SHREVEPORT
State	:	LA
Zip	:	71108-3859
Country	:	US
Telephone Number	:	318-631-2065
Fax Number	:	318-631-2067

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	:	12/22/2015

Similar Medicare Providers

1578870739 — JACQUELINE A MCCRAY DPH
Practice Location Address:

2640 WAGGONER AVE
SHREVEPORT, LA
71108-3859

Practice Phone: 318-631-2065
Practice Fax: 318-631-2067

1629337316 — MR. THOMAS FISHER RPH
Practice Location Address:

2640 WAGGONER AVE
SHREVEPORT, LA
71108-3859

Practice Phone: 318-631-2065
Practice Fax:

1942924287 — DR. DESTINY DUBOSE PHARM.D
Practice Location Address:

2640 WAGGONER AVE
SHREVEPORT, LA
71108-3859

Practice Phone: 318-631-2065
Practice Fax:

1447937701 — WALGREEN CO.
Practice Location Address:

2640 WAGGONER AVE
SHREVEPORT, LA
71108-3859

Practice Phone: 318-631-2065
Practice Fax:

1790798080 — PATTI F. BORNAMAN M.A.
Practice Location Address:

9435 MANSFIELD RD , SUITE 3B
SHREVEPORT, LA
71118-3859

Practice Phone: 318-686-0012
Practice Fax: 318-686-0012

1184367914 — BETTY CLARK
Practice Location Address:

1353 GLEN OAK PL
SHREVEPORT, LA
71103-3859

Practice Phone: 318-404-8644
Practice Fax:

Directions to “BROOKSHIRE GROCERY COMPANY ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.