Healthcare Provider Details

I. General information

NPI: 1386147627
Provider Name (Legal Business Name): BROOKSHIRE GROCERY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 02/14/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 HOSPITAL ROAD
NEW ROADS LA
70760
US

IV. Provider business mailing address

1600 WSW LOOP 323
TYLER TX
75701-8532
US

V. Phone/Fax

Practice location:
  • Phone: 225-638-5151
  • Fax: 225-638-5148
Mailing address:
  • Phone: 903-877-6514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number006546
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number006546
License Number StateLA

VIII. Authorized Official

Name: NEIL F DUCOTE
Title or Position: VP - PHARMACY
Credential:
Phone: 903-534-3478