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ST LUKE'S HEALTH SYSTEM
CAH131323-00 ST. LUKE'S WOOD RIVER MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. LUKE'S WOOD RIVER MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131323-00
Entity Address
100 HOSPITAL DRIVE
KETCHUM, ID 83340
Medicare Provider Number
131323
Participating Start Date
4/1/2011
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
ST LUKE'S HEALTH SYSTEM
Pharmacy Address
SPECIALTY PHARMACY
11801 W EXECUTIVE DR
BOISE, ID 83713
Pharmacy Comments
Contract Details
Approval Date
4/18/2022
Contract Begin Date
5/17/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Peter DiDio, Vice President, Controller
(208) 381-1251
Contract Pharmacy Representative
St. Luke's Health System, LTD
Tyler Hemsley, Director Pharmacy
(208) 706-9807
Signed By Date
4/18/2022
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