Healthcare Provider Details

I. General information

NPI: 1821161159
Provider Name (Legal Business Name): BROOKSHIRE GROCERY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 08/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W US HIGHWAY 80 ATTENTION PHARMACY DEPT
WHITE OAK TX
75693-2006
US

IV. Provider business mailing address

PO BOX 1411
TYLER TX
75710-1411
US

V. Phone/Fax

Practice location:
  • Phone: 903-297-9896
  • Fax: 903-297-9897
Mailing address:
  • Phone:
  • Fax:

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 Number19348
License Number StateTX

VIII. Authorized Official

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