Healthcare Provider Details

I. General information

NPI: 1821161399
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: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 US HIGHWAY 69 N ATTENTION PHARMACY DEPT
BULLARD TX
75757-5135
US

IV. Provider business mailing address

1600 W SW LOOP 323 PO BOX 1411
TYLER TX
75701-8532
US

V. Phone/Fax

Practice location:
  • Phone: 903-894-9648
  • Fax: 903-894-3860
Mailing address:
  • Phone: 903-877-6827
  • Fax: 903-877-3820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number22908
License Number StateTX

VIII. Authorized Official

Name: JIM COUSINEAU
Title or Position: VP PHARMACY OPERATIONS
Credential: RPH
Phone: 903-877-6514