Healthcare Provider Details

I. General information

NPI: 1710227202
Provider Name (Legal Business Name): BROOKSHIRE GROCERY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2013
Last Update Date: 12/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11205 N HWY 289
POTTSBORO TX
75076
US

IV. Provider business mailing address

11205 N HWY 289
POTTSBORO TX
75076
US

V. Phone/Fax

Practice location:
  • Phone: 903-786-3150
  • Fax: 903-786-3166
Mailing address:
  • Phone: 903-877-6827
  • Fax: 903-877-3820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28425
License Number StateTX

VIII. Authorized Official

Name: JIM COUSINEAU
Title or Position: SR VP PHARMACY OPS
Credential:
Phone: 903-877-6829