# BROOKSHIRE GROCERY COMPANY

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- **Entity:** Organization
- **Status:** Active
- **Other names:** SUPER 1 PHARMACY
- **Organization subpart:** No

## Provider details

- **NPI number:** 1760555239
- **Authorized official:** JIM COUSINEAU RPH (VP PHARMACY OPERATIONS)
- **Authorized official phone:** (903) 877-6514

## Contact information

- **Practice address:** 745 SHREVEPORT BARKSDALE HWY, ATTENTION PHARMACY DEPT, SHREVEPORT, LA 71105-2201
- **Practice address phone:** (318) 861-3985
- **Practice address fax:** (318) 861-4231
- **Mailing address:** 1600 W SW LOOP 323, PO BOX 1411, TYLER, TX 75701-8532
- **Mailing address phone:** (903) 877-6827
- **Mailing address fax:** (903) 877-3820

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 333600000X | Pharmacy | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | 4916 | LA | Yes |

## Other

- **Enumeration date:** 11/15/2006
- **Last updated:** 12/22/2015

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1269395 | — | LA |
| 01 | — | 2035070 | PK | — |