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AMAZON PHARMACY #001
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
AMAZON PHARMACY #001
Pharmacy Address
4500 S PLEASANT VALLEY RD STE 201
AUSTIN, TX 78744-2911
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
PillPack, Inc.
Geoff Swindle, Administrator
(855) 745-5725
Signed By Date
4/15/2019
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