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General NPI Number Information
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NPI Number | 1518300086
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Entity Type | Organization
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Legal Business Name | BROOKSHIRE GROCERY COMPANY
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Dates
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Enumeration Date | 04/15/2013
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Last Update Date | 07/30/2013
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Provider Practice Location Address
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Address Line | 2300 W ENNIS AVE
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City | ENNIS
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State | TX
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Zip | 75119-8039
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Country | US
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Telephone | 972-875-4607
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Fax | 972-875-2060
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Provider Business Mailing Address
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Address Line | PO BOX 1411
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City | TYLER
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State | TX
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Zip | 75710-1411
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Country | US
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Telephone | 903-877-6827
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Fax | 903-877-3820
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Authorized Official
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Title or Position | SR VP PHARMACY OPS
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Name | JIM COUSINEAU
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Credential |
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Telephone | 903-877-6829
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 28377
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License Number State | TX
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