NPIMap

Organization Active NPI

Broulim Supermarkets, LLC

  • Community/Retail Pharmacy
  • Ammon, ID
National Provider Identifier
1851854095
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
3160 E 17TH St Ste 164
Ammon, ID 83406-6784
Phone
(208) 529-1795
Fax
(833) 887-9908
NPI assigned
Apr 12, 2019
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 4

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

Addresses

Primary practice location

3160 E 17TH St Ste 164
Ammon, ID 83406-6784

Mailing address

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

Other identifiers 4

IdentifierTypeStateIssuer
1851854095MedicaidID
NR-51740OtherWYBOARD OF PHARMACY
1309954OtherNCPDP
53249RPOtherIDBOARD OF PHARMACY

Other names 1

  • Broulim's Pharmacy #17 - 17th Street 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.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
13D2167140Broulim'S Pharmacy #173160 E 17TH St Ste 164, Ammon, ID 83406Certificate of waiverJun 2, 2027

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.

NPI Registry JSON

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

{
    "created_epoch": "1555027200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1751500800000",
    "number": "1851854095",
    "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": "208-745-3431"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3160 E 17TH ST STE 164",
            "city": "AMMON",
            "state": "ID",
            "postal_code": "834066784",
            "telephone_number": "208-529-1795",
            "fax_number": "833-887-9908"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BROULIM SUPERMARKETS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-04-12",
        "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": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "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": "1851854095",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BOARD OF PHARMACY",
            "identifier": "NR-51740",
            "state": "WY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP",
            "identifier": "1309954",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BOARD OF PHARMACY",
            "identifier": "53249RP",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Broulim's Pharmacy #17 - 17th Street",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Ammon, 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.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.