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WAL-MART PHARMACY 10-3897
CAH131326-00 IHC Health Services Inc. DBA Intermountain Health Cassia Regional Hospital
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Covered Entity Details
Entity Name
IHC Health Services Inc. DBA Intermountain Health Cassia Regional Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131326-00
Entity Address
1501 Hiland Avenue
Burley, ID 83318
Medicare Provider Number
131326
Participating Start Date
4/1/2013
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3897
Pharmacy Address
WAL-MART STORES INC.
252 CHENEY DR W
TWIN FALLS, ID 83301
Pharmacy Comments
Contract Details
Approval Date
1/14/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/22/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ben Smalley, Administrator
(208) 677-6441
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/14/2019
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