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IDAHO CVS PHARMACY, L.L.C.
SCH130002-00 St. Luke's Magic Valley Regional Medical Center, LTD
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Covered Entity Details
Entity Name
St. Luke's Magic Valley Regional Medical Center, LTD
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH130002-00
Entity Address
801 Pole Line Rd.West
Twin Falls, ID 83301
Medicare Provider Number
130002
Participating Start Date
7/1/2013
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
IDAHO CVS PHARMACY, L.L.C.
Pharmacy Address
CVS PHARMACY # 16216
1611 BLUE LAKES BLVD N
TWIN FALLS, ID 83301
Pharmacy Comments
Contract Details
Approval Date
7/12/2020
Contract Begin Date
10/1/2020
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
7/12/2020
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