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HUB CITY DRUG
CAH131310-00 St Luke's Jerome, Ltd.
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Covered Entity Details
Entity Name
St Luke's Jerome, Ltd.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131310-00
Entity Address
709 NORTH LINCOLN AVE
JEROME, ID 83338
Medicare Provider Number
131310
Participating Start Date
9/30/2010
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
HUB CITY DRUG
Pharmacy Address
447 N IDAHO ST
WENDELL, ID 83355
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
Peter DiDio, Vice President, Controller
(208) 381-1251
Contract Pharmacy Representative
K2RED LLC
Daniel Fuchs, Member
(208) 878-6337
Signed By Date
4/14/2021
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