Provider Demographics
NPI:1538441381
Name:BROOKSHIRES GROCERY COMPANY
Entity type:Organization
Organization Name:BROOKSHIRES GROCERY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:SLOCUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:318-687-7558
Mailing Address - Street 1:388 BERT KOUNS LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-8123
Mailing Address - Country:US
Mailing Address - Phone:318-687-7558
Mailing Address - Fax:
Practice Address - Street 1:388 BERT KOUNS LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-8123
Practice Address - Country:US
Practice Address - Phone:318-687-7558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-16
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA019518183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1628OtherMEDICATION ADMINISTRATION NUMBER