Provider Demographics
NPI:1750811295
Name:BROOKSHIRE GROCERY COMPANY
Entity type:Organization
Organization Name:BROOKSHIRE GROCERY COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VP OF PHARMACY OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:COUSINEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-877-6829
Mailing Address - Street 1:200 DESTINATION POINTE LN.
Mailing Address - Street 2:
Mailing Address - City:SCOTT
Mailing Address - State:LA
Mailing Address - Zip Code:70583
Mailing Address - Country:US
Mailing Address - Phone:337-210-2001
Mailing Address - Fax:337-236-6531
Practice Address - Street 1:200 DESTINATION POINTE LN.
Practice Address - Street 2:
Practice Address - City:SCOTT
Practice Address - State:LA
Practice Address - Zip Code:70583
Practice Address - Country:US
Practice Address - Phone:337-210-2001
Practice Address - Fax:337-236-6531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
LA007485333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2169752OtherPK