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CREDENA HEALTH PHARMACY LAKESHORE
CAH271325-00 St. Luke Community Hospital & Nursing Home
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Covered Entity Details
Entity Name
St. Luke Community Hospital & Nursing Home
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH271325-00
Entity Address
107 6th Avenue SW
Ronan, MT 59864
Medicare Provider Number
271325
Participating Start Date
10/1/2013
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
CREDENA HEALTH PHARMACY LAKESHORE
Pharmacy Address
50331 US 93
POLSON, MT 59860-7046
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
Paul Soukup, CFO
(406) 676-4441 Ext: 291
Contract Pharmacy Representative
Providence. Health & Services
John Evans, Director, Retail Ops
(503) 215-6296
Signed By Date
1/15/2020
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