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CLEARWATER CANYON PHARMACY LLC
CAH131320-00 CLEARWATER VALLEY HOSPITAL
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Covered Entity Details
Entity Name
CLEARWATER VALLEY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131320-00
Entity Address
301 CEDAR ST
OROFINO, ID 83544
Medicare Provider Number
131320
Participating Start Date
4/1/2019
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
CLEARWATER CANYON PHARMACY LLC
Pharmacy Address
13020 HIGHWAY 12
OROFINO, ID 83544-9330
Pharmacy Comments
Contract Details
Approval Date
4/14/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jyl Ruland, CFO
(208) 476-8062
Contract Pharmacy Representative
Clearwater Canyon Pharmacy LLC
Andy Pottenger, Owner
(208) 476-0110
Signed By Date
4/14/2021
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