Organization
BROOKSHIRE GROCERY COMPANY
Active
Other names
BROOKSHIRES PHARMACY #59
Organization subpart
No
Provider details
NPI number
Authorized official
JIM D COUSINEAU RPH (VP PHARMACY OPERATIONS)
(903) 877-6829
Entity
Organization
Contact information
Practice address
1201 RIDGE RD, ATTENTION PHARMACY DEPT, ROCKWALL, TX 75087-4242
(972) 771-1446
(972) 722-8092
Mailing address
PO BO X 1411, ATTENTION PHARMACY DEPT, TYLER, TX 75710-1411
(972) 771-1446
(903) 877-3820
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
16076
TX
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1366515835
NPI
—
01
—
16076
TX STATE BOARD OF PHARMACY LICENSE
TX
01
—
4592463
OTHER ID NUMBER-COMMERCIAL NUMBER
—
05
—
463949
—
TX
01
—
DMEH29026
TMHP MEDICARE CROSSOVER TO TX MEDICAID
TX
01
—
H0089621
TX DPS
TX
01
—
PH0342
MEDICARE IMMUNIZATION BILLING--TRAILBLAZER
TX
Enumeration date
11/15/2006
Last updated
03/07/2023
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