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General NPI Number Information
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NPI Number | 1669935813
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Entity Type | Organization
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Legal Business Name | BROULIM SUPERMARKETS, LLC
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Dates
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Enumeration Date | 04/12/2019
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Last Update Date | 07/03/2025
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Provider Practice Location Address
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Address Line | 301 ASPEN SQ
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City | SAINT ANTHONY
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State | ID
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Zip | 83445-1662
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Country | US
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Telephone | 208-228-0424
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Fax | 844-721-6082
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Provider Business Mailing Address
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Address Line | 160 S CLARK ST
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City | RIGBY
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State | ID
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Zip | 83442-1407
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Country | US
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Telephone | 208-745-9201
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Fax | 208-745-3431
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Authorized Official
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Title or Position | PHARMACY DIRECTOR
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Name | DR. MARCUS C. HURST
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Credential | PHARMD
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Telephone | 208-745-9201
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0002X
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Taxonomy Name | Clinic Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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