Provider Demographics
NPI:1225478894
Name:BROULIM SUPERMARKETS, LLC
Entity Type:Organization
Organization Name:BROULIM SUPERMARKETS, LLC
Other - Org Name:BROULIM'S PHARMACY #4 - THAYNE
Other - Org Type:Other Name
Authorized Official - Title/Position:PHARMACY SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:C
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:307-883-6337
Mailing Address - Fax:208-883-6338
Practice Address - Street 1:118 PETERSEN PKWY
Practice Address - Street 2:
Practice Address - City:THAYNE
Practice Address - State:WY
Practice Address - Zip Code:83127
Practice Address - Country:US
Practice Address - Phone:307-883-6337
Practice Address - Fax:307-883-6338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-27
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy