Provider Demographics
NPI:1053410373
Name:BROOKSHIRE BROTHERS LTD
Entity type:Organization
Organization Name:BROOKSHIRE BROTHERS LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RAYBURN
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHUM
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:936-634-8155
Mailing Address - Street 1:1906 N FRAZIER ST
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77301-1240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1906 N FRAZIER ST
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-1240
Practice Address - Country:US
Practice Address - Phone:936-756-5566
Practice Address - Fax:936-756-5855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18304333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4592196OtherNCPDP
4592196OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TX464087Medicaid
TX464087Medicaid
4592196OtherNCPDP