Provider Demographics
NPI:1841678935
Name:BROULIM SUPERMARKETS, LLC
Entity type:Organization
Organization Name:BROULIM SUPERMARKETS, LLC
Other - Org Name:
Other - Org Type:
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:208-881-1989
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:208-745-9201
Mailing Address - Fax:208-745-7801
Practice Address - Street 1:118400 US HIGHWAY 26/89
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:WY
Practice Address - Zip Code:83128
Practice Address - Country:US
Practice Address - Phone:307-654-6337
Practice Address - Fax:307-887-7782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-11
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYR10153333600000X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy