Provider Demographics
NPI:1508926734
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 1:89 W 2ND S
Mailing Address - Street 2:
Mailing Address - City:SODA SPRINGS
Mailing Address - State:ID
Mailing Address - Zip Code:83276-1509
Mailing Address - Country:US
Mailing Address - Phone:208-547-3300
Mailing Address - Fax:208-547-3532
Practice Address - Street 1:89 W 2ND S
Practice Address - Street 2:
Practice Address - City:SODA SPRINGS
Practice Address - State:ID
Practice Address - Zip Code:83276-1509
Practice Address - Country:US
Practice Address - Phone:208-547-3300
Practice Address - Fax:208-547-3532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ID2098RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2129023OtherPK
ID1508926734Medicaid
1306162OtherNCPDP