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ALBERTSONS LLC
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
ALBERTSONS LLC
Pharmacy Address
SAV-ON PHARMACY #238
1024 21ST ST
LEWISTON, ID 83501
Pharmacy Comments
Contract Details
Approval Date
10/5/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
ALEX TOWN, CFO
(509) 758-4667
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
10/5/2016
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