Provider Demographics
NPI:1366515835
Name:BROOKSHIRE GROCERY COMPANY
Entity type:Organization
Organization Name:BROOKSHIRE GROCERY COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP PHARMACY OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:D
Authorized Official - Last Name:COUSINEAU
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-877-6829
Mailing Address - Street 1:PO BO X 1411
Mailing Address - Street 2:ATTENTION PHARMACY DEPT
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75710-1411
Mailing Address - Country:US
Mailing Address - Phone:972-771-1446
Mailing Address - Fax:903-877-3820
Practice Address - Street 1:1201 RIDGE RD
Practice Address - Street 2:ATTENTION PHARMACY DEPT
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-4242
Practice Address - Country:US
Practice Address - Phone:972-771-1446
Practice Address - Fax:972-722-8092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
TX16076333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1366515835OtherNPI
TXPH0342OtherMEDICARE IMMUNIZATION BILLING--TRAILBLAZER
4592463OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TXDMEH29026OtherTMHP MEDICARE CROSSOVER TO TX MEDICAID
TX16076OtherTX STATE BOARD OF PHARMACY LICENSE
TX463949Medicaid
TXH0089621OtherTX DPS
TXH0089621OtherTX DPS
BB4111225OtherDEA