Healthcare Provider Details

I. General information

NPI: 1730308503
Provider Name (Legal Business Name): BROOKSHIRE GROCERY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

Provider Other Name: BROOKSHIRE PHARMACY

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 W SOUTH COMMERCE ST
WILLS POINT TX
75169-2355
US

IV. Provider business mailing address

PO BOX 1411
TYLER TX
75710-1411
US

V. Phone/Fax

Practice location:
  • Phone: 903-873-8237
  • Fax: 903-873-8732
Mailing address:
  • Phone: 903-877-6862
  • Fax: 903-877-3820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number25507
License Number StateTX

VIII. Authorized Official

Name: JIM COUSINEAU
Title or Position: VP PHRM OPER
Credential:
Phone: 903-877-6829