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TETON PHARMACY IN AMMON
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
TETON PHARMACY IN AMMON
Pharmacy Address
3160 E. 17TH ST., SUITE 164
AMMON, ID 83406
Pharmacy Comments
Contract Details
Approval Date
4/6/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/19/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rachel Gonzales, CEO
(208) 356-3691
Contract Pharmacy Representative
Jason Bailey, owner
(208) 220-1807
Signed By Date
4/6/2017
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