Contract Pharmacy Details

LONDON DRUG
CAH131309-00 CARIBOU MEDICAL CENTER

Covered Entity Details

Entity Name

CARIBOU MEDICAL CENTER

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH131309-00

Entity Address

300 SOUTH 3RD WEST
SODA SPRINGS, ID 83276

Medicare Provider Number

131309

Participating Start Date

4/1/2011

Last Recertification Date

9/3/2024

Pharmacy Details

Pharmacy Name

LONDON DRUG

Pharmacy Address

#6 SOUTH MAIN
BOX 325
GRACE, ID 83241

Pharmacy Comments

Contract Details

Approval Date

1/14/2016

Contract Begin Date

4/1/2016

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

6/1/2016
Agreement registered in error

Contacts

Covered Entity Signing Official

JON SMITH, CEO
(208) 547-2765

Contract Pharmacy Representative

Kenna Cutler, Owner
(208) 425-3766

Signed By Date

1/14/2016