Contract Pharmacy Details

BROULIM'S PHARMACY
CH100180 HEALTH WEST INC

Covered Entity Details

Entity Name

HEALTH WEST INC

Subdivision Name

HEALTH WEST - ADMINISTRATION OFFICES

Type

HRSA-Funded Health Center

340B ID

CH100180

Entity Address

500 S 11th AVE
POCATELLO, ID 83201-4835

Grant Number

H80CS00321

Participating Start Date

4/1/2004

Last Recertification Date

2/12/2025

Pharmacy Details

Pharmacy Name

BROULIM'S PHARMACY

Pharmacy Address

89 W 2ND S
SODA SPRINGS, ID 83276-1509

Pharmacy Comments

Contract Details

Approval Date

1/14/2014

Contract Begin Date

4/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/1/2018
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Elizabeth Mahoney, CEO
(208) 232-7862 Ext: 1107

Contract Pharmacy Representative

Neil Hurley, Pharmacist
(208) 356-5416

Signed By Date

1/14/2014