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SCH130002-14 St. Luke's Magic Valley Regional Medical Center, LTD (Terminated)
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Main Details
Name
St. Luke's Magic Valley Regional Medical Center, LTD
Subdivision Name
SLC General Surgery - Shuss
Type
Sole Community Hospital
Rural
Yes
340B ID
SCH130002-14
Medicare Provider Number
130002
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/2/2013
Participating Start Date
7/1/2013
Participating Approval Date
5/3/2013
Last Recertification Date
8/13/2015
Termination Date
Termination Reason
7/1/2016
Site closure
Contacts
Authorizing Official
St. Lukes Regional Medical Center
Peter DiDio, Vice President, Controller
(208) 381-1251
Primary Contact
Craig Coy, Sr. Pharmacy Manager
(208) 814-2516
Addresses
Street Address
775 Pole Line Road West, Suite 216
Twin Falls, ID 83301
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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