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JACK'S PHARMACY INC
CAH131317-00 BENEWAH COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
BENEWAH COMMUNITY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131317-00
Entity Address
229 S 7TH STREET
ST MARIES, ID 83861
Medicare Provider Number
131317
Participating Start Date
10/1/2014
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
JACK'S PHARMACY INC
Pharmacy Address
103 EAST COLLEGE AVE
ST MARIES, ID 83861
Pharmacy Comments
Contract Details
Approval Date
7/11/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lori Minier, CFO
(208) 245-7609
Contract Pharmacy Representative
Jack's Pharmacy
Chad Brown, Owner
(208) 245-4578
Signed By Date
7/11/2018
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