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IDAHO STATE UNIVERSITY
CAH131324-00 Lost Rivers District Hospital
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Covered Entity Details
Entity Name
Lost Rivers District Hospital
Subdivision Name
Lost Rivers Medical Center
Type
Critical Access Hospital
340B ID
CAH131324-00
Entity Address
551 Highland Drive
Arco, ID 83213
Medicare Provider Number
131324
Participating Start Date
7/1/2013
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
IDAHO STATE UNIVERSITY
Pharmacy Address
BENGAL PHARMACY ARCO
551 HIGHLAND DR
ARCO, ID 83213
Pharmacy Comments
Contract Details
Approval Date
7/15/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Bradley Huerta, Administrator / CEO
(208) 252-7654 Ext: 701
Contract Pharmacy Representative
Bengal Pharmacy
Brady Brower, Pharmacy Director
(208) 282-3407
Signed By Date
7/15/2021
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