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WAL-MART PHARMACY 10-3739
DSH130013 Saint Alphonsus Medical Center Nampa
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Covered Entity Details
Entity Name
Saint Alphonsus Medical Center Nampa
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH130013
Entity Address
4300 East Flamingo Ave
NAMPA, ID 83687
Medicare Provider Number
130013
Participating Start Date
10/17/2005
Last Recertification Date
8/20/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3739
Pharmacy Address
5875 EAST FRANKLIN RD
NAMPA, ID 83687
Pharmacy Comments
Contract Details
Approval Date
4/10/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
KARL KEELER, CEO
(208) 463-5398
Contract Pharmacy Representative
Kathi Phelps, Manager Contracting & Channell Management
(479) 899-8830
Signed By Date
4/10/2013
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