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JEROME DRUG
CAH131302-00 NORTH CANYON MEDICAL CENTER
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Covered Entity Details
Entity Name
NORTH CANYON MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131302-00
Entity Address
267 NORTH CANYON DRIVE
GOODING, ID 83330
Medicare Provider Number
131302
Participating Start Date
10/1/2017
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
JEROME DRUG
Pharmacy Address
111 PIONEER CT
STE 2
JEROME, ID 83338-5193
Pharmacy Comments
Contract Details
Approval Date
10/12/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Sara DeMoe, Controller
(208) 934-4433 Ext: 1201
Contract Pharmacy Representative
Dicks Pharmacy
Doug Fuchs, Owner
(208) 734-7373
Signed By Date
10/12/2018
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