Healthcare Provider Details

I. General information

NPI: 1740448174
Provider Name (Legal Business Name): BROOKSHIRE GROCERY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 W WHITE ST
ANNA TX
75409-5007
US

IV. Provider business mailing address

PO BOX 1411
TYLER TX
75710-1411
US

V. Phone/Fax

Practice location:
  • Phone: 972-924-4220
  • Fax: 972-924-4773
Mailing address:
  • Phone: 903-877-6514
  • Fax: 903-877-3820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number25923
License Number StateTX

VIII. Authorized Official

Name: JIM COUSINEAU
Title or Position: VP OF PHCY OPER
Credential: RPH
Phone: 903-877-6829