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COMMUNITY MEDICAL CENTER PHARMACY
CAH131319-01 Minidoka Memorial Hospital
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Covered Entity Details
Entity Name
Minidoka Memorial Hospital
Subdivision Name
Minidoka Medical - RHC
Type
Critical Access Hospital
340B ID
CAH131319-01
Entity Address
1308 8th Street 1
Rupert, ID 83350
Medicare Provider Number
131319
Outpatient Facility Provider Number
138507
Participating Start Date
10/1/2016
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
COMMUNITY MEDICAL CENTER PHARMACY
Pharmacy Address
610 GATEWAY CENTER WAY
STE A - E
SAN DIEGO, CA 92102-4548
Pharmacy Comments
Contract Details
Approval Date
4/20/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/31/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jason Gibbons, CFO
(208) 436-8153
Contract Pharmacy Representative
Minidoka Memorial Hospital
Brenda Ward, Clinic Manager
(208) 434-8236
Signed By Date
4/20/2018
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