Organization
BROOKSHIRE GROCERY COMPANY
Active
Other names
SUPER 1 PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
JIM COUSINEAU RPH (VP PHARMACY OPERATIONS)
(903) 877-6514
Entity
Organization
Contact information
Practice address
2211 E MADISON AVE, ATTENTION PHARMACY DEPT, BASTROP, LA 71220-4072
(318) 281-3284
(318) 281-4408
Mailing address
1600 W SW LOOP 323, PO BOX 1411, TYLER, TX 75701-8532
(903) 877-6827
(903) 877-3820
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
3750
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1264539
—
LA
01
—
2033640
PK
—
Enumeration date
11/15/2006
Last updated
12/22/2015
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