Provider Demographics
NPI:1003969346
Name:BROULIM SUPERMARKETS LLC
Entity Type:Organization
Organization Name:BROULIM SUPERMARKETS LLC
Other - Org Name:BROULIMS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:
Authorized Official - Last Name:HURST
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:208-745-9201
Mailing Address - Street 1:160 S CLARK ST
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-1407
Mailing Address - Country:US
Mailing Address - Phone:208-356-5416
Mailing Address - Fax:208-356-5653
Practice Address - Street 1:124 W MAIN ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1827
Practice Address - Country:US
Practice Address - Phone:208-356-5416
Practice Address - Fax:208-356-5653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ID1280RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1003969346Medicaid
2129024OtherPK
1306299OtherNCPDP