340B Drug Pricing Program Database
Home
Search
Search Covered Entities
Search Contract Pharmacies
Search Manufacturers
Reports
Help
Login
BROULIM'S PHARMACY
DSH130025 MADISON MEMORIAL HOSPITAL
Print
Covered Entity Details
Entity Name
MADISON MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH130025
Entity Address
450 EAST MAIN
REXBURG, ID 83440
Medicare Provider Number
130025
Participating Start Date
7/1/2009
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
BROULIM'S PHARMACY
Pharmacy Address
124 W MAIN ST
REXBURG, ID 83440-1827
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Rachel Gonzales, CEO
(208) 356-3691
Contract Pharmacy Representative
Broulims Fresh Foods
Marcus Hurst, Pharmacy Manager
(208) 745-9201 Ext: 117
Signed By Date
1/15/2020
Continue Your Session
For security reasons inactive sessions are automatically closed.
Your session will be closed shortly if you don't continue it.
Continue Your Session