Healthcare Provider Details

I. General information

NPI: 1285707752
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: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 W FRANK ST ATTENTION PHARMACY DEPT
GRAND SALINE TX
75140-1757
US

IV. Provider business mailing address

PO BOX 1411 ATTN PHCY DEPT
TYLER TX
75710-1411
US

V. Phone/Fax

Practice location:
  • Phone: 903-962-4063
  • Fax: 903-962-4253
Mailing address:
  • Phone: 903-962-4063
  • Fax: 903-877-3820

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 TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number25127
License Number StateTX

VIII. Authorized Official

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