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SCH130002-08 St. Luke's Magic Valley Regional Medical Center, LTD (Active)
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Main Details
Name
St. Luke's Magic Valley Regional Medical Center, LTD
Subdivision Name
SLC Family Medicine - Waters
Type
Sole Community Hospital
Rural
Yes
340B ID
SCH130002-08
Medicare Provider Number
130002
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
5/15/2018
Participating Start Date
7/1/2018
Participating Approval Date
5/15/2018
Last Recertification Date
8/27/2024
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
550 Polk Street Suite B
Twin Falls, ID 83301
Billing Address
St. Luke's Health System, LTD
190 E Bannock St
Boise, ID 83712
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating from effective date (7/1/2013), until terminated effective date ( 1/1/2017), reinstatement date effective date (07/01/2018)
05/15/2018
May 2025
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