Provider Demographics
NPI:1508926734
Name:BROULIM SUPERMARKETS LLC
Entity type:Organization
Organization Name:BROULIM SUPERMARKETS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:DR
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:208-745-9201
Mailing Address - Fax:208-745-3431
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:855-847-9646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1508926734Medicaid
ID2098RPOtherBOARD OF PHARMACY
1306162OtherNCPDP