Basic Information
| Provider Information | |||||||||
| NPI: | 1316046634 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROOKSHIRE BROTHERS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BROOKSHIRE BROTHERS PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1201 ELLEN TROUT DR | ||||||||
| Address2: | |||||||||
| City: | LUFKIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759041233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9366348155 | ||||||||
| FaxNumber: | 9366334678 | ||||||||
| Practice Location | |||||||||
| Address1: | 513 E AUSTIN ST | ||||||||
| Address2: | |||||||||
| City: | GIDDINGS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 789423305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9795423308 | ||||||||
| FaxNumber: | 9795421658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALSTON | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9366348155 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | 18306 | TX | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2105361 | 01 | PK | OTHER | 464104 | 05 | TX | MEDICAID |