1649343971 NPI number — BROOKSHIRE GROCERY COMPANY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649343971 NPI number — BROOKSHIRE GROCERY COMPANY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOKSHIRE GROCERY COMPANY
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:
SUPER 1 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:
1649343971
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
BROOKSHIRE GROCERY COMPANY
Provider Second Line Business Mailing Address:
PO BOX 1411
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75710-1411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 S HIGH ST
Provider Second Line Business Practice Location Address:
ATTENTION PHARMACY DEPT
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75602-3210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-234-2785
Provider Business Practice Location Address Fax Number:
903-234-2789
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COUSINEAU
Authorized Official First Name:
JIM
Authorized Official Middle Name:
Authorized Official Title or Position:
VP PHARMACY OPERATIONS
Authorized Official Telephone Number:
903-877-6514

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 20343 , 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: 2093497 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 464505 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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