NPIMap

Organization Active NPI

Brookshire Grocery Company

Doing business as Brookshires Pharmacy

  • Community/Retail Pharmacy
  • Tyler, TX
National Provider Identifier
1609945591
Registry record updated Apr 11, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
15882 Issued in TX
Legal business name
BROOKSHIRE GROCERY COMPANY
Doing business as
Brookshires Pharmacy
Practice address
2020 Roseland Blvd
Attention Pharmacy Dept
Tyler, TX 75701-4248
Phone
(903) 597-1358
Fax
(903) 593-4681
NPI assigned
Nov 7, 2006
Last updated
Apr 11, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 11, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jim Cousineau, RPH
Title
VP Pharmacy Operations
Phone
(903) 877-6514

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X 15882 TX Primary

Addresses

Primary practice location

2020 Roseland Blvd
Attention Pharmacy Dept
Tyler, TX 75701-4248

Mailing address

1600 W SW Loop 323
PO Box 1411
Tyler, TX 75701-8532
Phone (903) 877-6827

Other identifiers 2

IdentifierTypeStateIssuer
463950MedicaidTX
2102400OtherPK

Other names 1

  • BROOKSHIRES PHARMACY Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080801000492 TX Part B Supplier - Mass Immunization (Roster Biller Only) 1355415712

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory

Locations

2020 Roseland Blvd
Tyler, TX 75701
Phone (903) 597-1358

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1162857600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1460332800000",
    "number": "1609945591",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1600 W SW LOOP 323",
            "address_2": "PO BOX 1411",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757018532",
            "telephone_number": "903-877-6827",
            "fax_number": "903-877-3820"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2020 ROSELAND BLVD",
            "address_2": "ATTENTION PHARMACY DEPT",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757014248",
            "telephone_number": "903-597-1358",
            "fax_number": "903-593-4681"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BROOKSHIRE GROCERY COMPANY",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-07",
        "last_updated": "2016-04-11",
        "status": "A",
        "authorized_official_last_name": "COUSINEAU",
        "authorized_official_first_name": "JIM",
        "authorized_official_title_or_position": "VP PHARMACY OPERATIONS",
        "authorized_official_telephone_number": "903-877-6514",
        "authorized_official_credential": "RPH"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "TX",
            "license": "15882",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "463950",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2102400",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "BROOKSHIRES PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Tyler, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 11, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.