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SHOPKO PHARMACY #2072
CAH501332-00 TRI-STATE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
TRI-STATE MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH501332-00
Entity Address
1221 HIGHLAND AVE
CLARKSTON, WA 99403
Medicare Provider Number
501332
Participating Start Date
9/30/2010
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
SHOPKO PHARMACY #2072
Pharmacy Address
2120 THAIN GRADE
LEWISTON, ID 83501
Pharmacy Comments
Contract Details
Approval Date
8/6/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/4/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
ALEX TOWN, CFO
(509) 758-4667
Contract Pharmacy Representative
Shopko
Tad Schilke, Director of Rx Merchandising & Marketing
(920) 429-7628
Signed By Date
8/6/2014
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