13D2167140 CLIA NUMBER - BROULIM'S PHARMACY #17

Laboratory Demographics

  • CLIA Code: 13D2167140
  • Facility Name: BROULIM'S PHARMACY #17
  • Facility Address: 3160 E 17TH ST STE 164
    AMMON, ID
    ZIP 83406
  • Facility Phone: 208 529-1795
  • Facility Type: Pharmacy
  • Facility Type: Waiver
  • Lab Director: MARCUS C. HURST PHARMD
  • NPI Number: 1851854095
  • Taxonomy: 3336C0003X - Pharmacy

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CLIA Record

Field Name Field Value
CLIA Number 13D2167140
LAB Type Pharmacy
Facility Name BROULIM'S PHARMACY #17
Street 3160 E 17TH ST STE 164
City AMMON
State ID
ZIP 83406
Phone 208 529-1795
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 6/3/2025
Certificate Expiration Date 6/2/2027
Facility Type Pharmacy
Lab Director MARCUS C. HURST PHARMD

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This page was last updated on: 9/29/2025