No
St. Luke's Elmore Medical Center
Attn: Pharmacy
895 N. Sixth East
Mountain Home, ID 83647
St Lukes Central Pharmacy
703 S Black Cat Rd, Suite 130
Meridian, ID 83642
| Contract Detail | ALBERTSONS LLC | SAV-ON PHARMACY #165 |
528 NORTH MAIN ST
| MOUNTAIN HOME | ID | 83647 | 01/15/2018 | 04/01/2018 | | | 01/15/2018 |
| Contract Detail | WAL-MART CENTRAL FILL 10-2670 | 608 SPRING HILL DR # 3 SUITE 300 |
| SPRING | TX | 77386 | 01/12/2018 | 04/01/2018 | | | 04/17/2023 |
| Contract Detail | WAL-MART PHARMACY 10-2782 | 2745 AMERICAN LEGION BLVD |
| MOUNTAIN HOME | ID | 83647 | 01/12/2018 | 04/01/2018 | | | 04/17/2023 |
| Contract Detail | WAL-MART PHARMACY 10-5997 | 9600 PARKSOUTH CT. SUITE 100 |
| ORLANDO | FL | 32837 | 01/12/2018 | 04/01/2018 | | | 04/17/2023 |
| Contract Detail | WALMART PHARMACY 10-5169 | 2252 NORTH 8TH STREET |
SUITE A
| ROGERS | AR | 72756 | 04/17/2023 | 07/01/2023 | | | 07/01/2023 |
| Contract Detail | Walmart Pharmacy 10-7611 | 2501 Perry Rd |
| Plainfield | IN | 46168 | 10/05/2023 | 01/01/2024 | | | 01/01/2024 |
| CAH131311-01 | Child | CAH | ST. LUKE'S ELMORE MEDICAL CENTER | Outpatient Services - Elmore Regional Clinic Outpatient Services | 890 N 6th E | Mountain Home | ID | Active |
| CAH131311-02 | Child | CAH | ELMORE MEDICAL CENTER | General Surgery Clinic - ClinicElmore St. Lukes General Surgery Clinic | 840 N 4TH E STREET | Mountain Home | ID | Terminated |
| CAH131311-03 | Child | CAH | ELMORE MEDICAL CENTER | Elmore St. Lukes PVL/ECHO - ECHOCARDIOLOGY | 840 N 4TH E STREET | Mountain Home | ID | Terminated |
| CAH131311-04 | Child | CAH | ST. LUKE'S ELMORE MEDICAL CENTER | Trinity Mountain Medical Clinic - St Lukes Trinity Mountain Pediatrics | 465 McKenna Drive | Mountain Home | ID | Active |
| CAH131311-05 | Child | CAH | ST. LUKE'S ELMORE MEDICAL CENTER | Trinity Mountain Medical Clinic - St. Lukes Trinity Mountain Obstetrics | 465 McKenna Drive | Mountain Home | ID | Active |
| CAH131311-06 | Child | CAH | ST. LUKE'S ELMORE MEDICAL CENTER | Trinity Mountain Medical Clinic - St Lukes Trinity Mountain Internal Med | 465 McKenna Drive | Mountain Home | ID | Terminated |
| CAH131311-07 | Child | CAH | ST. LUKE'S ELMORE MEDICAL CENTER | Trinity Mountain Medical Clinic - St. Lukes Mountain Family Med | 465 McKenna Drive | Mountain Home | ID | Active |
| CAH131311-08 | Child | CAH | ST. LUKE'S ELMORE MEDICAL CENTER | ELMORE ST LUKES FAMILY/INTERNAL MEDICINE CLINIC | 805 N 6TH STREET E | MOUNTAIN HOME | ID | Active |
| Addresses | Shipping Address | Update | Change Request | St Lukes Central Pharmacy
703 Black Cat Rd, Suite 130
Meridian, ID 83642 | St Lukes Central Pharmacy
703 S Black Cat Rd, Suite 130
Meridian, ID 83642 | 10/23/2024 2:25 PM |
| Addresses | Shipping Address | Insert | Change Request | | St Lukes Central Pharmacy
703 Black Cat Rd, Suite 130
Meridian, ID 83642 | 9/26/2024 9:39 AM |
| Details | Last Recertification Date | Update | Recertification | 9/1/2023 6:29:08 AM | 8/27/2024 1:04:46 PM | 8/27/2024 1:04 PM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2022 6:30:25 AM | 9/1/2023 6:29:08 AM | 9/1/2023 6:29 AM |
| 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 11:13 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 6:53:20 AM | 9/8/2022 6:30:25 AM | 9/8/2022 6:30 AM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2020 9:09:20 AM | 9/13/2021 6:53:20 AM | 9/13/2021 6:53 AM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2019 1:05:53 AM | 9/7/2020 9:09:20 AM | 9/7/2020 9:09 AM |
| Details | Last Recertification Date | Update | Recertification | 8/28/2018 6:54:15 AM | 9/7/2019 1:05:53 AM | 9/7/2019 1:05 AM |
| Details | Entity Name | Update | Change Request | ELMORE MEDICAL CENTER | ST. LUKE'S ELMORE MEDICAL CENTER | 5/15/2019 12:19 PM |
| Addresses | Billing Address | Insert | Recertification | | St. Luke's Health System, LTD
190 E Bannock
Boise, ID 83712 | 8/28/2018 6:54 AM |
| Details | Last Recertification Date | Update | Recertification | | 8/28/2018 6:54:15 AM | 8/28/2018 6:54 AM |
| 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 10:52 AM |
| Contacts | Primary Contact | Update | Change Request | Davis, Amanda
Pharmacy Business Specialist
St. Lukes Regional Medical Center
2087061021 | Jackson, Shana E
Pharmacy Business Analyst
St. Luke's Magic Valley Regional Medical Center
2088149611 | 1/12/2018 1:14 PM |
| Details | State | Update | | Approved | Active | 1/1/2018 12:00 AM |
| Contacts | Signed By | Insert | New Registration | | DiDio, Peter
Vice President, Controller
St. Lukes Regional Medical Center
2083811251 | 10/17/2017 8:19 AM |
| Details | 340B ID | Update | New Registration | | CAH131311-00 | 10/17/2017 8:19 AM |
| Dates | Participating Approval Date | Update | New Registration | | 10/17/2017 12:19:57 PM | 10/17/2017 8:19 AM |
| Details | State | Update | New Registration | Pending | Approved | 10/17/2017 8:19 AM |
| Dates | Signed By Date | Update | New Registration | | 10/16/2017 6:44:37 PM | 10/17/2017 8:19 AM |
| Dates | Start Date | Update | New Registration | | 1/1/2018 12:00:00 AM | 10/17/2017 8:19 AM |
| Addresses | Main Address | Insert | New Registration | |
895 N. SIXTH EAST
MOUNTAIN HOME, ID 83647 | 10/16/2017 5:24 PM |
| Addresses | Shipping Address | Insert | New Registration | | St. Luke's Elmore Medical Center
Attn: Pharmacy
895 N. Sixth East
Mountain Home, ID 83647 | 10/16/2017 5:24 PM |
| Contacts | Primary Contact | Insert | New Registration | | Davis, Amanda
Pharmacy Business Specialist
St. Lukes Regional Medical Center
2087061021 | 10/16/2017 5:24 PM |
| Contacts | Authorizing Official | Insert | New Registration | | DiDio, Peter
Vice President, Controller
St. Lukes Regional Medical Center
2083811251 | 10/16/2017 5:24 PM |
| Details | Last Recertification Date | Insert | New Registration | | | 10/16/2017 5:24 PM |
| Details | Grant Number | Insert | New Registration | | | 10/16/2017 5:24 PM |
| Details | 340B ID | Insert | New Registration | | | 10/16/2017 5:24 PM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 10/16/2017 5:24 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 10/16/2017 5:24 PM |
| Details | Medicare Provider Number | Insert | New Registration | | 131311 | 10/16/2017 5:24 PM |
| Details | Entity Name | Insert | New Registration | | ELMORE MEDICAL CENTER | 10/16/2017 5:24 PM |
| Details | Program Code | Insert | New Registration | | CAH | 10/16/2017 5:24 PM |
| Details | Entity Subname | Insert | New Registration | | | 10/16/2017 5:24 PM |
| Dates | Participating Approval Date | Insert | New Registration | | | 10/16/2017 5:24 PM |
| Details | State | Insert | New Registration | | Pending | 10/16/2017 5:24 PM |
| Dates | Registration Date | Insert | New Registration | | 10/16/2017 5:24:24 PM | 10/16/2017 5:24 PM |
| Dates | Signed By Date | Insert | New Registration | | | 10/16/2017 5:24 PM |
| Dates | Start Date | Insert | New Registration | | | 10/16/2017 5:24 PM |
| Terminations | Termination Comments | Insert | New Registration | | | 10/16/2017 5:24 PM |
| Terminations | Termination Date | Insert | New Registration | | | 10/16/2017 5:24 PM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 10/16/2017 5:24 PM |
| Terminations | Termination Reason | Insert | New Registration | | | 10/16/2017 5:24 PM |