Healthcare Provider Details

I. General information

NPI: 1659615078
Provider Name (Legal Business Name): BROULIM SUPERMARKETS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 N WASHINGTON ST
AFTON WY
83110
US

IV. Provider business mailing address

160 S CLARK ST
RIGBY ID
83442-1407
US

V. Phone/Fax

Practice location:
  • Phone: 307-885-5055
  • Fax: 855-841-5350
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 HURST
Title or Position: PHARMACY DIRECTOR
Credential: PHARMD
Phone: 208-745-9201