340B Drug Pricing Program Database
Home
Search
Search Covered Entities
Search Contract Pharmacies
Search Manufacturers
Reports
Help
Login
BROULIMS PHARMACY #1 RIGBY
DSH130025 MADISON MEMORIAL HOSPITAL
Print
Covered Entity Details
Entity Name
MADISON MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH130025
Entity Address
450 EAST MAIN
REXBURG, ID 83440
Medicare Provider Number
130025
Participating Start Date
7/1/2009
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
BROULIMS PHARMACY #1 RIGBY
Pharmacy Address
150 N STATE ST
RIGBY, ID 83442-1443
Pharmacy Comments
Contract Details
Approval Date
12/6/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/8/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rachel Gonzales, CEO
(208) 356-3691
Contract Pharmacy Representative
Neil Hurley, Pharmacist
(208) 356-5416
Signed By Date
10/12/2012
Continue Your Session
For security reasons inactive sessions are automatically closed.
Your session will be closed shortly if you don't continue it.
Continue Your Session