Organization
BROOKSHIRE GROCERY COMPANY
Active
Other names
Super 1 Foods Pharmacy #642
Organization subpart
No
Provider details
NPI number
Authorized official
JIM COUSINEAU (SENIOR VP PHARMACY OPERATIONS)
(903) 877-6829
Entity
Organization
Contact information
Practice address
172 CENTENNIAL PKWY, TYLER, TX 75703
(903) 525-6923
(903) 581-2421
Mailing address
PO BOX 1411, ATTENTION PHARMACY DEPARTMENT, TYLER, TX 75710-1411
(903) 877-6862
(903) 877-3820
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
Primary
30243
TX
3336C0003X
Community/Retail Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2154729
PK
—
05
—
470992
—
TX
Enumeration date
10/21/2015
Last updated
09/21/2016
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