1720132178 NPI number — BROULIM SUPERMARKETS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720132178 NPI number — BROULIM SUPERMARKETS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROULIM SUPERMARKETS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BROULIMS PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720132178
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
182 N STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIGBY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83442-1444
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-745-9201
Provider Business Mailing Address Fax Number:
208-745-7433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 N STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIGBY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83442-1443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-745-0267
Provider Business Practice Location Address Fax Number:
208-745-0208
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HURST
Authorized Official First Name:
MARCUS
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PHARMACY SUPERVISOR
Authorized Official Telephone Number:
208-745-9201

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  1090CP , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1305831 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1912011 . This is a "MEDICARE NORIDIAN" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1720132178 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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