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WALMART PHARMACY 10-5169
DSH130007 Saint Alphonsus Regional Medical Center
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Covered Entity Details
Entity Name
Saint Alphonsus Regional Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH130007
Entity Address
1055 N. Curtis Rd.
Boise, ID 83706
Medicare Provider Number
130007
Participating Start Date
4/1/2012
Last Recertification Date
8/20/2024
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
10/17/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lannie Checketts, RHM CFO Idaho Oregon Region
(208) 367-7347
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting 340b
(303) 261-5549
Signed By Date
10/17/2023
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