NPIMap

Organization Active NPI

Broulim Supermarkets, LLC

  • Community/Retail Pharmacy
  • Rexburg, ID
National Provider Identifier
1003969346
Registry record updated Jul 3, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
Legal business name
BROULIM SUPERMARKETS, LLC
Practice address
124 W Main St
Rexburg, ID 83440-1827
Phone
(208) 356-5416
Fax
(866) 238-5784
NPI assigned
Jan 19, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 3, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Marcus Hurst, PHARMD
Title
Pharmacy Director
Phone
(208) 745-9201

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X
Clinic Pharmacy 3336C0002X
Community/Retail Pharmacy 3336C0003X Primary

Addresses

Primary practice location

124 W Main St
Rexburg, ID 83440-1827

Mailing address

160 S Clark St
Rigby, ID 83442-1407
Phone (208) 356-5416

Other identifiers 2

IdentifierTypeStateIssuer
1003969346MedicaidID
1280RPOtherIDBOARD OF PHARMACY

Other names 1

  • Broulim's Pharmacy #6 - Rexburg Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110928000334 ID Part B Supplier - Mass Immunization (Roster Biller Only) 5890966691 9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Rigby, ID; Soda Springs, ID; Shelley, ID; Saint Anthony, ID; Rexburg, ID; Idaho Falls, ID; Driggs, ID; Ammon, ID…

Other NPIs on the same Medicare enrollment 9

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Broulim Supermarkets LLC12 organizations share this tax ID, including this one

Other organizations with this tax ID 11

Organizations that report the same tax identification number in the National Provider Directory.

Locations

124 W Main St
Rexburg, ID 83440
Phone (208) 356-5416

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1169164800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1751500800000",
    "number": "1003969346",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "160 S CLARK ST",
            "city": "RIGBY",
            "state": "ID",
            "postal_code": "834421407",
            "telephone_number": "208-356-5416",
            "fax_number": "208-356-5653"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "124 W MAIN ST",
            "city": "REXBURG",
            "state": "ID",
            "postal_code": "834401827",
            "telephone_number": "208-356-5416",
            "fax_number": "866-238-5784"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BROULIM SUPERMARKETS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-19",
        "last_updated": "2025-07-03",
        "certification_date": "2025-07-03",
        "status": "A",
        "authorized_official_last_name": "HURST",
        "authorized_official_first_name": "MARCUS",
        "authorized_official_title_or_position": "PHARMACY DIRECTOR",
        "authorized_official_telephone_number": "208-745-9201",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PHARMD"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0002X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Clinic Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1003969346",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BOARD OF PHARMACY",
            "identifier": "1280RP",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Broulim's Pharmacy #6 - Rexburg",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Rexburg, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 3, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.