Contract Pharmacy Details

WALLACE DRUG
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

WALLACE DRUG

Pharmacy Address

44 S MAIN ST.
BOX 841
ABERDEEN, ID 83210

Pharmacy Comments

Contract Details

Approval Date

1/12/2015

Contract Begin Date

4/1/2015

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Mindy Benedetti, CEO
(208) 232-7862 Ext: 1120

Contract Pharmacy Representative

Dwight Wallace, Owner
(208) 397-4540

Signed By Date

1/12/2015