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CAREMARK PUERTO RICO SPECIALTY PHARMACY,
CAH131323-00 ST. LUKE'S WOOD RIVER MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. LUKE'S WOOD RIVER MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131323-00
Entity Address
100 HOSPITAL DRIVE
KETCHUM, ID 83340
Medicare Provider Number
131323
Participating Start Date
4/1/2011
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
CAREMARK PUERTO RICO SPECIALTY PHARMACY,
Pharmacy Address
CAREMARK PUERTO RICO SPECIALTY PHARMACY
6020 AVE ROBERTO SANCHEZ VILELLA
CAROLINA, PR 00982
Pharmacy Comments
Contract Details
Approval Date
7/12/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/22/2021
Business decision by covered entity and/or pharmacy
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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