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WAL-MART PHARMACY 10-4249
CAH131314-00 SHOSHONE MEDICAL CENTER
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Covered Entity Details
Entity Name
SHOSHONE MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131314-00
Entity Address
25 jacobs Gulch
KELLOGG, ID 83837
Medicare Provider Number
131314
Participating Start Date
10/1/2018
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-4249
Pharmacy Address
583 COMMERCE DRIVE
SMELTERVILLE, ID 83868
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jerry Brantz, CEO/CFO
(208) 784-7017
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/15/2018
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