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WESTERN PHARMACY GROUP LLC
CAH131324-00 Lost Rivers District Hospital
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Covered Entity Details
Entity Name
Lost Rivers District Hospital
Subdivision Name
Lost Rivers Medical Center
Type
Critical Access Hospital
340B ID
CAH131324-00
Entity Address
551 Highland Drive
Arco, ID 83213
Medicare Provider Number
131324
Participating Start Date
7/1/2013
Last Recertification Date
8/15/2024
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
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/6/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Bradley Huerta, Administrator / CEO
(208) 252-7654 Ext: 701
Contract Pharmacy Representative
Western Pharmacy Group LLC
KEVIN FARIS, CEO
(360) 685-4263
Signed By Date
4/15/2019
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