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WAL-MART PHARMACY 10-5315
DSH130071 St. Luke's Nampa Medical Center
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Covered Entity Details
Entity Name
St. Luke's Nampa Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH130071
Entity Address
9850 W ST LUKES DRIVE
Nampa, ID 83687
Medicare Provider Number
130071
Participating Start Date
7/1/2019
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
7/1/2020
Contract Begin Date
8/25/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/15/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Peter DiDio, Vice President, Controller
(208) 381-1251
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/1/2020
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