1285707752 NPI number — BROOKSHIRE GROCERY COMPANY

Table of content: (NPI 1285707752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285707752 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:
Provider Other Organization Name Type Code:
6
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:
1285707752
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1411
Provider Second Line Business Mailing Address:
ATTN PHCY DEPT
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:
903-962-4063
Provider Business Mailing Address Fax Number:
903-877-3820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 W FRANK ST
Provider Second Line Business Practice Location Address:
ATTENTION PHARMACY DEPT
Provider Business Practice Location Address City Name:
GRAND SALINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75140-1757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-962-4063
Provider Business Practice Location Address Fax Number:
903-962-4253
Provider Enumeration Date:
11/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COUSINEAU
Authorized Official First Name:
JIM
Authorized Official Middle Name:
D
Authorized Official Title or Position:
VP PHARMACY OPERATIONS
Authorized Official Telephone Number:
903-877-6829

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 25127 , 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: 25127 . This is a "TX STATE BOARD OF PHARMACY LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: PH0342 . This is a "MEDICARE IMMUNIZATION BILLING--TRAILBLAZER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 145708 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1285707752 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: R0148456 . This is a "TX DPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 4542608 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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