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WALGREEN CO.
CAH131319-00 Minidoka Memorial Hospital
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Covered Entity Details
Entity Name
Minidoka Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131319-00
Entity Address
1224 8th St
Rupert, ID 83350
Medicare Provider Number
131319
Participating Start Date
7/1/2012
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #13673
904 E MAIN ST
BURLEY, ID 83318
Pharmacy Comments
Contract Details
Approval Date
7/14/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jason Gibbons, CFO
(208) 436-8153
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/14/2021
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