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WALMART PHARMACY 10-4494
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
WALMART PHARMACY 10-4494
Pharmacy Address
622 E. USTICK ROAD
CALDWELL, ID 83605
Pharmacy Comments
Contract Details
Approval Date
4/3/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Peter DiDio, Vice President, Controller
(208) 381-1251
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/3/2017
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