=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851854095
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROULIM SUPERMARKETS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2019
-----------------------------------------------------
Last Update Date | 07/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3160 E 17TH ST STE 164
-----------------------------------------------------
City | AMMON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83406-6784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-529-1795
-----------------------------------------------------
Fax | 833-887-9908
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 160 S CLARK ST
-----------------------------------------------------
City | RIGBY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83442-1407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-745-9201
-----------------------------------------------------
Fax | 208-745-3431
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY DIRECTOR
-----------------------------------------------------
Name | DR. MARCUS HURST
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 208-745-9201
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------