1396979712 NPI number — BROOKSHIRE BROTHERS INC

Table of content: (NPI 1396979712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396979712 NPI number — BROOKSHIRE BROTHERS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOKSHIRE BROTHERS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BROOKSHIRE BROTHERS PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396979712
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201 ELLEN TROUT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUFKIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75904-1233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-634-8155
Provider Business Mailing Address Fax Number:
936-633-4678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 S HOME ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORRIGAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75939-2616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-398-9227
Provider Business Practice Location Address Fax Number:
936-398-9477
Provider Enumeration Date:
05/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ALSTON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT CEO
Authorized Official Telephone Number:
936-634-8155

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  26365 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2120204 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 466607 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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