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ALBERTSONS LLC
DSH130013 Saint Alphonsus Medical Center Nampa
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Covered Entity Details
Entity Name
Saint Alphonsus Medical Center Nampa
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH130013
Entity Address
4300 East Flamingo Ave
NAMPA, ID 83687
Medicare Provider Number
130013
Participating Start Date
10/17/2005
Last Recertification Date
8/20/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
ALBERTSONS LLC
Pharmacy Address
ALBERTSONS PHARMACY #3195
3499 E FAIRVIEW AVE.
MERIDIAN, ID 83642
Pharmacy Comments
Contract Details
Approval Date
4/9/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lannie Checketts, RHM CFO Idaho Oregon Region
(208) 367-7347
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
4/9/2019
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