NPIMap

Organization Active NPI

Broulim Supermarkets, LLC

Doing business as Broulim's Pharmacy #9 - Shelley

  • Community/Retail Pharmacy
  • Shelley, ID
National Provider Identifier
1396870911
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
Doing business as
Broulim's Pharmacy #9 - Shelley
Practice address
570 S State St
Shelley, ID 83274-1470
Phone
(208) 357-0473
Fax
(844) 721-6089
NPI assigned
Feb 22, 2007
Last updated
Jul 3, 2025By the provider in NPPES
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 C Hurst, PHARMDNPI 1447666128
Title
Pharmacy Director
Phone
(208) 745-9201

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X NU
Pharmacy 333600000X NU
Clinic Pharmacy 3336C0002X NU
Community/Retail Pharmacy 3336C0003X NU Primary

Addresses

Primary practice location

570 S State St
Shelley, ID 83274-1470

Mailing address

160 S Clark St
Rigby, ID 83442-1407
Phone (208) 745-9201

Other identifiers 3

IdentifierTypeStateIssuer
1396870911MedicaidID
1307493OtherNCPDP
1876RPOtherIDBOARD OF PHARMACY

Other names 1

  • Broulim's Pharmacy #9 - Shelley 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.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1172102400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1751500800000",
    "number": "1396870911",
    "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": "208-745-9201",
            "fax_number": "208-745-7433"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "570 S STATE ST",
            "city": "SHELLEY",
            "state": "ID",
            "postal_code": "832741470",
            "telephone_number": "208-357-0473",
            "fax_number": "844-721-6089"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BROULIM SUPERMARKETS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-22",
        "last_updated": "2025-07-03",
        "certification_date": "2025-07-03",
        "status": "A",
        "authorized_official_last_name": "HURST",
        "authorized_official_first_name": "MARCUS",
        "authorized_official_middle_name": "C",
        "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": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0002X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Clinic Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1396870911",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP",
            "identifier": "1307493",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BOARD OF PHARMACY",
            "identifier": "1876RP",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Broulim's Pharmacy #9 - Shelley",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Shelley, 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.