Provider Demographics
NPI:1659615078
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:C
Authorized Official - Last Name:HURST
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:208-745-9201
Mailing Address - Street 1:182 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-1444
Mailing Address - Country:US
Mailing Address - Phone:208-745-9201
Mailing Address - Fax:208-745-7433
Practice Address - Street 1:141 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110
Practice Address - Country:US
Practice Address - Phone:307-886-5550
Practice Address - Fax:307-885-5057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYR100903336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW25566OtherIMMUNIZATION SUPPLIER NSC
WYWY0157Medicaid
5204463OtherNCPDP PROVIDER IDENTIFICATION NUMBER