Broulim Supermarkets, LLC
Organization Active NPI Community/Retail Pharmacy · Saint Anthony, ID
NPI 1669935813 · NPPES record last updated Jul 3, 2025
Key facts
- NPI
- 1669935813
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- Legal business name
- BROULIM SUPERMARKETS, LLC
- Practice address
- 301 Aspen SQ
Saint Anthony, ID 83445-1662 - Phone
- (208) 228-0424
- Fax
- (844) 721-6082
- NPI assigned
- Apr 12, 2019
- Organization subpart
- No
Authorized official
- Name
- Dr. Marcus C. Hurst, PHARMD
- Title
- Pharmacy Director
- Phone
- (208) 745-9201
Other NPIs on the same Medicare enrollment 9
Corporate family (same tax ID) 11
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 13D2167279 | Broulim'S Pharmacy #5 | Certificate of waiver | Jun 4, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in ID
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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… |
National Provider Directory
- Tax ID family
- Broulim Supermarkets LLC
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacy | 333600000X | |||
| Clinic Pharmacy | 3336C0002X | |||
| Community/Retail Pharmacy | 3336C0003X | Yes |
Addresses
Primary practice location
301 Aspen SQ
Saint Anthony, ID 83445-1662
Mailing address
160 S Clark St
Rigby, ID 83442-1407
Phone (208) 745-9201
Other names
- Broulim's Pharmacy #5 -Saint Anthony
Other providers in Saint Anthony, ID
- Back Country Chiropractic PLLC
- Kent A Beesley
- Erin Joanne Benson
- Larry Miles Bradley
- Gabel C Brizzee
- Andrew Logan Brower
- Julie Harker Buck
- Haddi Burr
- Stephen J. Cheyne
- County of Fremont
All providers in Saint Anthony, ID · Community/Retail Pharmacy in Idaho
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 3, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.