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IDAHO CVS PHARMACY, L.L.C.
DSH130006 ST LUKES REGIONAL MEDICAL CENTER, LTD.
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Covered Entity Details
Entity Name
ST LUKES REGIONAL MEDICAL CENTER, LTD.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH130006
Entity Address
190 EAST BANNOCK
BOISE, ID 83712
Medicare Provider Number
130006
Participating Start Date
7/1/2004
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
IDAHO CVS PHARMACY, L.L.C.
Pharmacy Address
CVS/PHARMACY # 11169
7402 WEST FAIRVIEW AVE
BOISE, ID 83704
Pharmacy Comments
Contract Details
Approval Date
4/15/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Peter DiDio, Vice President, Controller
(208) 381-1251
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/15/2020
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