Healthcare Provider Details

I. General information

NPI: 1669935813
Provider Name (Legal Business Name): BROULIM SUPERMARKETS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 ASPEN SQ
SAINT ANTHONY ID
83445-1662
US

IV. Provider business mailing address

160 S CLARK ST
RIGBY ID
83442-1407
US

V. Phone/Fax

Practice location:
  • Phone: 208-228-0424
  • Fax: 844-721-6082
Mailing address:
  • Phone: 208-745-9201
  • Fax: 208-745-3431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. MARCUS C. HURST
Title or Position: PHARMACY DIRECTOR
Credential: PHARMD
Phone: 208-745-9201