Provider Demographics
NPI:1902979479
Name:BROOKSHIRE GROCERY COMPANY
Entity Type:Organization
Organization Name:BROOKSHIRE GROCERY COMPANY
Other - Org Name:SUPER 1 PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP PHARMACY OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:COUSINEAU
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-877-6514
Mailing Address - Street 1:1600 W SW LOOP 323
Mailing Address - Street 2:PO BOX 1411
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8532
Mailing Address - Country:US
Mailing Address - Phone:903-877-6827
Mailing Address - Fax:903-877-3820
Practice Address - Street 1:207 E END BLVD N
Practice Address - Street 2:ATTENTION PHARMACY DEPT
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-3603
Practice Address - Country:US
Practice Address - Phone:903-938-3096
Practice Address - Fax:903-938-3097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
TX157293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX463945Medicaid
2101937OtherPK
TX463945Medicaid
TX463945Medicaid
4590293OtherOTHER ID NUMBER-COMMERCIAL NUMBER
0140873-01OtherTMHP TEXAS MEDICAID DME OR MEDICARE CROSSOVER
TX15729OtherTX STATE BOARD PHARMACY LICENSE
BB3920786OtherDEA
TXPH0342OtherMEDICARE IMMUNIZATION BILLING-TRAILBLAZER