NPIMap

Organization Active NPI

Brookshire Grocery Company

Doing business as Super 1 Pharmacy

  • Community/Retail Pharmacy
  • Bossier City, LA
National Provider Identifier
1770656241
Registry record updated Dec 22, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
3291 Issued in LA
Legal business name
BROOKSHIRE GROCERY COMPANY
Doing business as
Super 1 Pharmacy
Practice address
1870 Airline Dr
Attention Pharmacy Dept
Bossier City, LA 71112-2702
Phone
(318) 746-8401
Fax
(318) 746-8401
NPI assigned
Nov 15, 2006
Last updated
Dec 22, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 22, 2015

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 3291 LA Primary

Addresses

Primary practice location

1870 Airline Dr
Attention Pharmacy Dept
Bossier City, LA 71112-2702

Mailing address

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

Other identifiers 2

IdentifierTypeStateIssuer
1263273MedicaidLA
2033530OtherPK

Other names 1

  • SUPER 1 PHARMACY Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20091104000210 LA Part B Supplier - Mass Immunization (Roster Biller Only) 1355415712 38 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Shreveport, LA; Monroe, LA; Natchitoches, LA; New Iberia, LA; New Roads, LA; Opelousas, LA; Pineville, LA; Ruston, LA…

Other NPIs on the same Medicare enrollment 38

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 38

National Provider Directory

National Provider Directory

NPI Registry JSON

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

{
    "created_epoch": "1163548800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1450742400000",
    "number": "1770656241",
    "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": "1870 AIRLINE DR",
            "address_2": "ATTENTION PHARMACY DEPT",
            "city": "BOSSIER CITY",
            "state": "LA",
            "postal_code": "711122702",
            "telephone_number": "318-746-8401",
            "fax_number": "318-746-8401"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BROOKSHIRE GROCERY COMPANY",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-15",
        "last_updated": "2015-12-22",
        "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": "LA",
            "license": "3291",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1263273",
            "state": "LA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2033530",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SUPER 1 PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Bossier City, LA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 22, 2015; 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.