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ALBERTSONS LLC
DSH130025 MADISON MEMORIAL HOSPITAL
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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
ALBERTSONS LLC
Pharmacy Address
SAV-ON PHARMACY #171
490 NORTH 2ND EAST
REXBURG, ID 83440
Pharmacy Comments
Contract Details
Approval Date
1/11/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Rachel Gonzales, CEO
(208) 356-3691
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
1/11/2017
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