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SHOPKO PHARMACY #2104
CH100180 HEALTH WEST INC
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Covered Entity Details
Entity Name
HEALTH WEST INC
Subdivision Name
HEALTH WEST - ADMINISTRATION OFFICES
Type
HRSA-Funded Health Center
340B ID
CH100180
Entity Address
500 S 11th AVE
POCATELLO, ID 83201-4835
Grant Number
H80CS00321
Participating Start Date
4/1/2004
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
SHOPKO PHARMACY #2104
Pharmacy Address
747 SOUTH MAIN
BRIGHAM CITY, UT 84302
Pharmacy Comments
Contract Details
Approval Date
4/9/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/16/2024
Agreement registered in error
Contacts
Covered Entity Signing Official
Mark T Horrocks, Chief Medical Officer
(208) 232-7862
Contract Pharmacy Representative
Kroger Health
Eva Brumfield, Strategic Program Director
(651) 357-2109
Signed By Date
4/9/2024
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