Brookshire Grocery Company

Primary specialty

PharmacyTaxonomy code 333600000X

License

30243 Issued in TX

Legal business name

BROOKSHIRE GROCERY COMPANY

Doing business as

Super 1 Foods Pharmacy #642

Practice address

172 Centennial Pkwy
Tyler, TX 75703

Phone

(903) 525-6923

Fax

(903) 581-2421

NPI assigned

Oct 21, 2015

Organization subpart

No

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

Authorized official

Name

Jim Cousineau

Title

Senior VP Pharmacy Operations

Phone

(903) 877-6829

Specialties & licenses 2

Addresses

Other identifiers 2

Other names 1

• Super 1 Foods Pharmacy #642 Doing business as

Medicare fee-for-service enrollment

Enrolled in TX

Enrollment records 1

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

{
    "created_epoch": "1445385600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1474416000000",
    "number": "1962874602",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1411",
            "address_2": "ATTENTION PHARMACY DEPARTMENT",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757101411",
            "telephone_number": "903-877-6862",
            "fax_number": "903-877-3820"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "172 CENTENNIAL PKWY",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "75703",
            "telephone_number": "903-525-6923",
            "fax_number": "903-581-2421"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BROOKSHIRE GROCERY COMPANY",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-10-21",
        "last_updated": "2016-09-21",
        "status": "A",
        "authorized_official_last_name": "COUSINEAU",
        "authorized_official_first_name": "JIM",
        "authorized_official_title_or_position": "SENIOR VP PHARMACY OPERATIONS",
        "authorized_official_telephone_number": "903-877-6829"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "TX",
            "license": "30243",
            "primary": true
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2154729",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "470992",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Super 1 Foods Pharmacy #642",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Brookshire Grocery Company (Super 1 Pharmacy)
• Brookshire Grocery Company (Brookshires Pharmacy)
• Brookshire Grocery Company
• Brookshire Grocery Company (Super 1 Pharmacy)
• Brookshire Grocery Company (Brookshires Pharmacy #41)
• Daniel Ray Broom, D.C.
• La' Toya Broughton
• Matthew Brousseau
• Elizabeth Brown Ford, SLPA
• Amberniqua Brown

• Pharmacy in Tyler, TX
• Providers in Tyler, TX by specialty
• Pharmacy in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 21, 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.