Organization
BROOKSHIRE GROCERY COMPANY
Active
Other names
BROOKSHIRES PHARMACY #41
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
113 N NORTHWEST LOOP 323, ATTENTION PHARMACY DEPT, TYLER, TX 75702-8725
(903) 593-5369
(903) 593-3490
Mailing address
PO BOX 1411, TYLER, TX 75710-1411
(903) 593-5369
(903) 877-6909
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
21365
TX
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1922171495
NPI
—
01
—
21365
TX STATE BOARD OF PHARMACY LICENSE
TX
01
—
4521147
OTHER ID NUMBER-COMMERCIAL NUMBER
—
05
—
465110
—
TX
01
—
J0122303
TX DPS
TX
01
—
PH0342
MEDICARE IMMUNIZATION BILLING-TRAILBLAZER
TX
Enumeration date
11/15/2006
Last updated
03/07/2023
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