Healthcare Provider Details

I. General information

NPI: 1396818860
Provider Name (Legal Business Name): BROOKSHIRE GROCERY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 RIDGEWOOD RD ATTENTION PHARMACY DEPT
JACKSON MS
39211-2618
US

IV. Provider business mailing address

PO BOX 1411 ATTENTION PHARMACY DEPT
TYLER TX
75710-1411
US

V. Phone/Fax

Practice location:
  • Phone: 601-978-1747
  • Fax: 601-978-3150
Mailing address:
  • Phone: 601-978-1747
  • Fax: 903-877-6909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number05104 / 01.2
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JIM D COUSINEAU
Title or Position: VP PHARMACY OPERATIONS
Credential: RPH
Phone: 903-877-6829