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WESTERN PHARMACY GROUP LLC
CAH131319-00 Minidoka Memorial Hospital
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Covered Entity Details
Entity Name
Minidoka Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131319-00
Entity Address
1224 8th St
Rupert, ID 83350
Medicare Provider Number
131319
Participating Start Date
7/1/2012
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WESTERN PHARMACY GROUP LLC
Pharmacy Address
DBA COMMUNITY MEDICAL CENTER PHARMACY
610 GATEWAY CENTER WAY
SUITES A--E
SAN DIEGO, CA 92102
Pharmacy Comments
Contract Details
Approval Date
7/17/2018
Contract Begin Date
10/1/2018
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
Western Pharmacy Group LLC
KEVIN FARIS, CEO
(360) 685-4263
Signed By Date
7/17/2018
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