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WALMART PHARMACY 10-5169
CAH131314-00 SHOSHONE MEDICAL CENTER
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Covered Entity Details
Entity Name
SHOSHONE MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131314-00
Entity Address
25 jacobs Gulch
KELLOGG, ID 83837
Medicare Provider Number
131314
Participating Start Date
10/1/2018
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
4/3/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Donja C Erdman, Chief Financial Officer
(208) 784-1221
Contract Pharmacy Representative
Shoshone Medical Center
Alicia Mitchell, Pharmacy Tech
(208) 784-7017 Ext: 349
Signed By Date
4/3/2023
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