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Walgreens #21435
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
Walgreens #21435
Pharmacy Address
Walgreens Central Fill #21435
6306 S Airport Rd
West Jordan, UT 84084-5601
Pharmacy Comments
Contract Details
Approval Date
10/3/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kate Fowler, Senior VP & CFO
(208) 381-8717
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/3/2023
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