Healthcare Provider Details

I. General information

NPI: 1013080589
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

1310 N BRAZOS ST ATTENTION PHARMACY DEPT
WHITNEY TX
76692-2010
US

IV. Provider business mailing address

PO BOX 1411
TYLER TX
75710-1411
US

V. Phone/Fax

Practice location:
  • Phone: 254-694-4413
  • Fax: 254-694-4418
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 Number21346
License Number StateTX

VIII. Authorized Official

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