Covered Entity Details

SCH130002-24 St. Luke's Magic Valley Regional Medical Center, LTD (Active) - information as of 5/29/2025 1:57:44 AM

Main Details

Name

St. Luke's Magic Valley Regional Medical Center, LTD

Subdivision Name

SLC Rheumatology

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH130002-24

Medicare Provider Number

130002

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/2/2013

Participating Start Date

7/1/2013

Participating Approval Date

5/3/2013

Last Recertification Date

8/29/2024

Contacts

Authorizing Official

St. Luke's Health System, LTD
Kate Fowler, Senior VP & CFO
(208) 381-8717

Primary Contact

St. Luke's Health System, LTD
Amanda Davis, Pharmacy Business Analyst
(208) 706-1021

Addresses

Street Address

801 POLE LINE ROAD W SUITE 3810
Twin Falls, ID 83301

Billing Address

St. Luke's Health System, LTD
190 E Bannock
Boise, ID 83712

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

Shipping Addresses

Shipping Address 1

St. Luke's Magic Valley Regional Medical Center Attn: Pharmacy
801 Pole Line Rd. West
Twin Falls, ID 83301

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
SCH130002-01	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	COUMADIN CLINIC	550 POLK ST STE A	Twin Falls	ID	Active
SCH130002-02	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Congestive Heart Failure	775 Pole Line Road West, Suite 112	Twin Falls	ID	Active
SCH130002-03	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC INTERNAL MEDICINE ADDISON	2550 Addison Avenue East, Suite E	Twin Falls	ID	Active
SCH130002-04	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Internal Medicine - SRIM	625 Pole Line Road Suite 2A	Twin Falls	ID	Active
SCH130002-05	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC General Surgery - McClusky	775 Pole Line Road West, Suite 214	Twin Falls	ID	Terminated
SCH130002-06	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Cardiology - SICA	775 Pole Line Road West, Suite 112	Twin Falls	ID	Active
SCH130002-07	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC OB Gynecology - MVWH	775 Pole Line Road W. Suite 312	Twin Falls	ID	Active
SCH130002-08	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Family Medicine - Waters	550 Polk Street Suite B	Twin Falls	ID	Active
SCH130002-09	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Peds/Family Practice - PHYSICIAN CENTER-TWIN FALLS	775 Pole Line Road West, Suite 105 and 111	Twin Falls	ID	Active
SCH130002-10	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Peds/Family Practice - ADDSN-MAGIC VALLEY ST LUKES PHYSICIAN CENTER	2550 Addison Avenue East, Suite A,B and F	Twin Falls	ID	Active
SCH130002-11	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Family Med - Renaissance/ST LUKES PHYSICIAN CENTER-TWIN FALLS	730 North College Road, Suite A & B	Twin Falls	ID	Active
SCH130002-12	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Ped Ortho Surg	738 North College Road, Suite A	Twin Falls	ID	Terminated
SCH130002-13	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	MVCL-SL NEPHROLOGY-NARASIMHAN/GENOA ST. LUKES NEPHROLOGY -TWIN FALLS	746 North College Road, Suite A	Twin Falls	ID	Active
SCH130002-14	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC General Surgery - Shuss	775 Pole Line Road West, Suite 216	Twin Falls	ID	Terminated
SCH130002-15	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Ortho Plastic Surg-PALER ST LUKES ORTHOPEDICS AND PLASTIC SURGERY-TWIN FALLS	738 North College Road, Suite A & C	Twin Falls	ID	ToBeTerminated
SCH130002-16	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	MVCL SL NEUROLOGY	1840 CANYON CREST DRIVE	Twin Falls	ID	Active
SCH130002-17	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Physiatry - Wiggins & Myers	738 North College Road, Suite C	Twin Falls	ID	Terminated
SCH130002-18	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC General Surgery - SIGS	775 Pole Line Road West, Suite 212	Twin Falls	ID	Active
SCH130002-19	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Ent Facial Plast Surg - ENT	625 Pole Line Road Suite 2B	Twin Falls	ID	Active
SCH130002-20	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Gastroenterology - BLGI	775 Pole Line Road West, Suite 203	Twin Falls	ID	Active
SCH130002-21	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	St Luke's Vascular Surgery	775 Pole Line Road West, Suite 213	Twin Falls	ID	Active
SCH130002-22	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Physical Medicine & Rehab	625 Pole Line Road Suite 1A	Twin Falls	ID	Active
SCH130002-23	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	St. Luke's Urology	775 Pole Line Road West, Suite 301	Twin Falls	ID	Active
SCH130002-24	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Rheumatology	801 POLE LINE ROAD W SUITE 3810	Twin Falls	ID	Active
SCH130002-25	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Pulmonology	775 Pole Line Road West, Suite 315	Twin Falls	ID	Active
SCH130002-26	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Twin Falls Orthopedics-ST LUKES PODIATRY-TWIN FALLS	762 N COLLEGE RD STE A	Twin Falls	ID	Active
SCH130002-27	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Behavioral Health	414 Shoup Avenue West Suite B	Twin Falls	ID	Terminated
SCH130002-28	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Chronic Disease Mgmt (Endocrine/Diabetes Clinic)	625 Pole Line Road Suite 2A	Twin Falls	ID	Active
SCH130002-29	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Surgicalists	775 Pole Line Road West, Suite 214	Twin Falls	ID	Terminated
SCH130002-30	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Dermatology	714 North College Road, Suite B	Twin Falls	ID	Active
SCH130002-31	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC PRIMARY CARE ACCESS/ST LUKES MVMP QUICK CARE-TWIN FALLS	775 Pole Line Road West, Suite 103	Twin Falls	ID	Active
SCH130002-32	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC Physician Center (Buhl)	980 Burley Avenue	Buhl	ID	Active
SCH130002-33	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC PAIN MANAGEMENT	625 Pole Line Road Suite 1A	Twin Falls	ID	Active
SCH130002-34	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	St. Luke's SICA / Nuclear Medicine	775 Pole Line Road W. Suite 112	Twin Falls	ID	Active
SCH130002-35	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ENDOSCOPY/MVMP ST LUKES ENDOSCOPY	775 Pole Line Road West Suite 203	Twin Falls	ID	Active
SCH130002-36	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKES CLINIC ORTHOPEDICS / SPORTS MEDICINE	714 N COLLEGE RD STE A	Twin Falls	ID	Active
SCH130002-37	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKES REHAB CHILDRENS POLE LINE - MAGIC VALLEY MEDICAL CLINIC ST LUKES CHILDRENS PHYSICAL THERAPY TWIN FALLS	801 POLE LINE ROAD W SUITE 3802	Twin Falls	ID	Active
SCH130002-38	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	PALLIATIVE MEDICINE - ST LUKES PALLIATIVE MEDICINE-TWIN FALLS	625 Pole Line Rd. W Suite 2A	Twin Falls	ID	Active
SCH130002-39	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	RADIOLOGY - MAGIC VALLEY MEDICAL PLAZA DIAGNOSTIC XRAY FL 1 and FL3	775 POLE LINE ROAD W	Twin Falls	ID	Active
SCH130002-40	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	Surgery Center - Magic Valley Surgery Center	575 POLE LINE ROAD W	Twin Falls	ID	Active
SCH130002-41	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	Sleep Center - EPP ST LUKES SLEEP MEDICINE INSTITUTE-TWIN FALLS	450 Falls Avenue Suite 202	Twin Falls	ID	Active
SCH130002-42	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKES PHYS MED AND REHAB - Magic Valley Plaza 2 St. Lukes Clinic Spine Care-TWIN FALLS	625 Pole Line Road Suite 1A	Twin Falls	ID	Terminated
SCH130002-43	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKES PEDS/ FAMILY PRACTICE - MAGIC VALLEY MEDICAL PLAZA ST LUKES CHILDRENS CARDIOLOGY	775 POLE LINE ROAD W SUITE 111	Twin Falls	ID	Active
SCH130002-44	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	Coumadin Clinic - Anticoagulation Clinic Oncology Magic Valley	725 POLE LINE RD WEST	Twin Falls	ID	Terminated
SCH130002-45	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	Respiratory Therapy - Respiratory Therapy/Magic Valley St. Luke's Clinic Cardiopulmonary Rehabilitation	2550 ADDISON AVENUE E SUITE C	Twin Falls	ID	Active
SCH130002-46	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	MVHL-HOME HEALTH - HOME CARE MAGIC VALLEY	601 POLE LINE RD	TWIN FALLS	ID	Active
SCH130002-47	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKE'S CLINIC OBSTETRICS AND GYNECOLOGY	801 POLE LINE ROAD W SUITE 3880	Twin Falls	ID	Active
SCH130002-48	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	MVHL-HOSPICE - MVHL-HOSPICE-MAGIC VALLEY	601 POLE LINE ROAD	Twin Falls	ID	Active
SCH130002-49	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKES CLINIC WOUND CARE AND OSTOMY-TWIN FALLS	775 POLE LINE ROAD W SUITE 115	Twin Falls	ID	Active
SCH130002-50	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	DIABETES MED MGMT - MAGIC VALLEY MEDICAL PLAZA 2 ST LUKES CLINIC DIABETES EDUCATION CENTER-TWIN FALLS	625 POLE LINE ROAD W SUITE 2A	TWIN FALLS	ID	Active
SCH130002-51	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SL NEUROLOGY - MAGIC VALLEY CANYON CREST ST LUKES CLINIC NEUROPSYCHOLOGY	1840 Canyon Crest Drive	Twin Falls	ID	Active
SCH130002-52	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SL NEUROLOGY - MAGIC VALLEY CANYON CREST ST LUKES CLINIC PHYSICAL MED AND REHAB	1840 Canyon Crest Drive	Twin Falls	ID	Active
SCH130002-53	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SL FAMILY/PEDS PRACTICE - MAGIC VALLEY CHILDRENS SURGERY TWIN FALLS	775 POLE LINE RD W STE 302	Twin Falls	ID	Active
SCH130002-54	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ECHO - MAGIC VALLEY MEDICAL PLAZA PROCEDURAL SICA	775 POLE LINE RD W STE 112	Twin Falls	ID	Active
SCH130002-55	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC PEDS/FAMILY PRACTICE-ADDSN - ST. LUKE'S PHYSICIAN CENTER CLINIC SUITE B-TWIN FALLS	2550 ADDISON AVE E STE B	TWIN FALLS	ID	Active
SCH130002-56	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SLC PEDS/FAMILY PRACTICE-ADDSN - ST. LUKE'S PHYSICIAN CENTER CLINIC SUITE F-TWIN FALLS	2550 ADDISON AVE E, STE F	TWIN FALLS	ID	Active
SCH130002-57	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST. LUKE'S CLINIC BEHAVIORAL HEALTH	980 BURLEY AVE	BUHL	ID	Active
SCH130002-58	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SL OB/GYNECOLOGY - MVWH - ST LUKE'S WEST END CLINIC OBSTETRICS AND GYNECOLOGY-BUHL	980 BURLEY AVE	Buhl	ID	Terminated
SCH130002-59	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	SL CARDIOLOGY - SICA - ST LUKE'S WEST END CLINIC CARDIOLOGY-BUHL	980 BURLEY AVE	Buhl	ID	Active
SCH130002-60	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKE'S BEHAVIORAL HEALTH - ST LUKE'S BEHAVIORAL HEALTH-TWIN FALLS	815 N COLLEGE RD	TWIN FALLS	ID	Active
SCH130002-61	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKE'S CARDIAC REHAB - ST LUKE'S CARDIOPULMONARY REHABILITATION-TWIN FALLS	754 N COLLEGE RD STE A	TWIN FALLS	ID	Active
SCH130002-62	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKES INTERNAL MEDICINE - ST LUKES CLINIC INTERNAL MEDICINE-BUHL	980 BURLEY AVE	Buhl	ID	Active
SCH130002-63	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKES OB/GYNECOLOGY-MVWH - ST LUKES CLINIC MATERNAL FETAL MEDICINE-TWIN FALLS	775 POLE LINE RD. W STE 312	Twin Falls	ID	Active
SCH130002-64	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKES REHAB CHILDRENS - ST LUKES CHILDRENS PHYSICAL THERAPY ADDISON	2550 ADDISION AVE E STE D	TWIN FALLS	ID	Active
SCH130002-65	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKES PERIPHERAL VASCULAR LAB - ST LUKES CLINIC PROCEDURAL VASCULAR-TWIN FALLS	775 POLE LINE RD. W STE 213	Twin Falls	ID	Active
SCH130002-66	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKES REHAB ADULT - PHYSICAL THERAPY-TWIN FALLS	625 POLE LINE RD W STE 2B	TWIN FALLS	ID	Active
SCH130002-67	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKE'S - BEHAVIORAL HEALTH	228 SHOUP AVE W	TWIN FALLS	ID	Active
SCH130002-68	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKES RESPIRATORY THERAPY - PULMONARY FUNCTION LAB	775 POLE LINE RD W, STE 315	TWIN FALLS	ID	Active
SCH130002-69	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKES INFUSION CENTER - INFUSION SERVICES	801 POLE LINE RD W	TWIN FALLS	ID	Active
SCH130002-70	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKES CLINIC/OBSTETRICS AND GYNECOLOGY - MVMC SLC OBSTETRICS AND GYNECOLOGY SUITE 3880 ULTRASOUND	801 POLE LINE RD W STE 3880	Twin Falls	ID	Active
SCH130002-71	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKES RADIOLOGY - INTERVENTIONAL RADIOLOGY	625 POLE LINE RD W STE 1A	TWIN FALLS	ID	Approved
SCH130002-72	Child	SCH	St. Luke's Magic Valley Regional Medical Center, LTD	ST LUKES CLINIC PEDS FAMILY PRACTICE - CHILDRENS NEUROLOGY	775 POLE LINE RD STE 302	TWIN FALLS	ID	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/23/2023 4:07:46 PM	8/29/2024 6:18:28 PM	8/29/2024 6:18 PM
Details	Last Recertification Date	Update	Recertification	9/16/2022 12:04:12 AM	8/23/2023 4:07:46 PM	8/23/2023 4:07 PM
Contacts	Authorizing Official	Update	Change Request	DiDio, Peter Vice President, Controller St. Lukes Regional Medical Center 2083811251	Fowler, Kate Senior VP & CFO St. Luke's Health System, LTD 2083818717	11/16/2022 7:11 AM
Contacts	Primary Contact	Update	Profile Change Request	Davis, Amanda Pharmacy Business Specialist St. Lukes Regional Medical Center 2087061021	Davis, Amanda Pharmacy Business Analyst St. Luke's Health System, LTD 2087061021	11/15/2022 9:54 AM
Details	Last Recertification Date	Update	Recertification	9/13/2021 12:03:21 AM	9/16/2022 12:04:12 AM	9/16/2022 12:04 AM
Details	Last Recertification Date	Update	Recertification	8/26/2020 11:43:11 AM	9/13/2021 12:03:21 AM	9/13/2021 12:03 AM
Details	Last Recertification Date	Update	Recertification	9/6/2019 1:14:02 AM	8/26/2020 11:43:11 AM	8/26/2020 11:43 AM
Details	Last Recertification Date	Update	Recertification	8/28/2018 3:04:47 PM	9/6/2019 1:14:02 AM	9/6/2019 1:14 AM
Addresses	Main Address	Update	Change Request	775 Pole Line Road West, Suite115 Twin Falls, ID 83301	801 POLE LINE ROAD W SUITE 3810 Twin Falls, ID 83301	1/10/2019 9:35 AM
Addresses	Billing Address	Insert	Recertification		St. Luke's Health System, LTD 190 E Bannock Boise, ID 83712	8/28/2018 3:04 PM
Details	Last Recertification Date	Update	Recertification	11/20/2017 11:22:55 AM	8/28/2018 3:04:47 PM	8/28/2018 3:04 PM
Contacts	Primary Contact	Update	Change Request	Jackson, Shana E Pharmacy Business Analyst St. Luke's Magic Valley Regional Medical Center 2088149611	Davis, Amanda Pharmacy Business Specialist St. Lukes Regional Medical Center 2087061021	3/29/2018 10:54 AM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	11/20/2017 11:22:55 AM	11/20/2017 11:22 AM
Contacts	Primary Contact	Update	Change Request	Coy, Craig Sr. Pharmacy Manager 2088142516	Jackson, Shana E Pharmacy Business Analyst St. Luke's Magic Valley Regional Medical Center 2088149611	10/6/2017 1:59 PM
Contacts	Authorizing Official	Update		DiDio, Peter Vice President, Controller 2083811251	DiDio, Peter Vice President, Controller St. Lukes Regional Medical Center 2083811251	10/4/2017 2:42 PM
Contacts	Authorizing Official	Insert			DiDio, Peter Vice President, Controller 2083811251	8/10/2017 3:00 PM
Contacts	Signed By	Insert			Angle, James CEO 2088140005	5/17/2017 3:39 PM
Addresses	Main Address	Insert			775 Pole Line Road West, Suite115 Twin Falls, ID 83301	5/17/2017 3:39 PM
Addresses	Shipping Address	Insert			St. Luke's Magic Valley Regional Medical Center Attn: Pharmacy 801 Pole Line Rd. West Twin Falls, ID 83301	5/17/2017 3:39 PM
Details	Last Recertification Date	Update		8/13/2015 12:00:00 AM	8/17/2016 12:00:00 AM	8/17/2016 4:12 PM
Contacts	Primary Contact	Update		Cahoon, CJ Pharmacy Director 2088142516	Coy, Craig Sr. Pharmacy Manager 2088142516	4/21/2016 2:12 PM
Contacts	Primary Contact	Insert			Cahoon, CJ Pharmacy Director 2088142516	8/17/2015 4:27 PM
Details	Last Recertification Date	Update		8/21/2014 12:00:00 AM	8/13/2015 12:00:00 AM	8/13/2015 12:59 PM
Details	Last Recertification Date	Update		8/22/2013 10:42:50 AM	8/21/2014 12:00:00 AM	8/21/2014 7:45 AM
Details	Last Recertification Date	Update			8/22/2013 10:42:50 AM	8/22/2013 10:42 AM
Details	340B ID	Update		ISAPSCH130002-24	SCH130002-24	5/3/2013 2:17 PM
Dates	Participating Approval Date	Update			5/3/2013 12:00:00 AM	5/3/2013 2:17 PM
Details	State	Update		Pending	Active	5/3/2013 2:17 PM
Dates	Start Date	Update			7/1/2013 12:00:00 AM	5/3/2013 2:17 PM
Details	340B ID	Update		ISAPDSH130002-24	ISAPSCH130002-24	4/10/2013 3:45 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	ISAPDSH130002-24	4/10/2013 3:44 PM
Details	Last Recertification Date	Insert				4/2/2013 5:09 PM
Details	Grant Number	Insert				4/2/2013 5:09 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/2/2013 5:09 PM
Details	Is Authorizing Official EHB Data	Insert				4/2/2013 5:09 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/2/2013 5:09 PM
Details	Medicare Provider Number	Insert			130002	4/2/2013 5:09 PM
Details	Entity Name	Insert			St. Luke's Magic Valley Regional Medical Center, LTD	4/2/2013 5:09 PM
Details	Program Code	Insert			SCH	4/2/2013 5:09 PM
Details	Entity Subname	Insert			SLC Rheumatology	4/2/2013 5:09 PM
Dates	Participating Approval Date	Insert				4/2/2013 5:09 PM
Details	State	Insert			Pending	4/2/2013 5:09 PM
Dates	Registration Date	Insert			4/2/2013 12:00:00 AM	4/2/2013 5:09 PM
Dates	Signed By Date	Insert			4/2/2013 12:00:00 AM	4/2/2013 5:09 PM
Dates	Start Date	Insert				4/2/2013 5:09 PM
Terminations	Termination Comments	Insert				4/2/2013 5:09 PM
Terminations	Termination Date	Insert				4/2/2013 5:09 PM
Terminations	Termination Effective Date	Insert				4/2/2013 5:09 PM
Terminations	Termination Reason	Insert				4/2/2013 5:09 PM