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WAL-MART PHARMACY 10-2781
DSH130006 ST LUKES REGIONAL MEDICAL CENTER, LTD.
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Covered Entity Details
Entity Name
ST LUKES REGIONAL MEDICAL CENTER, LTD.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH130006
Entity Address
190 EAST BANNOCK
BOISE, ID 83712
Medicare Provider Number
130006
Participating Start Date
7/1/2004
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2781
Pharmacy Address
2100 12TH AVENUE ROAD
NAMPA, ID 83686
Pharmacy Comments
Contract Details
Approval Date
1/15/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Chris Roth, CEO
(208) 381-2860
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/15/2014
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