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IHC HEALTH SERVICES, INC.
CAH131323-00 ST. LUKE'S WOOD RIVER MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. LUKE'S WOOD RIVER MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131323-00
Entity Address
100 HOSPITAL DRIVE
KETCHUM, ID 83340
Medicare Provider Number
131323
Participating Start Date
4/1/2011
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
IHC HEALTH SERVICES, INC.
Pharmacy Address
DBA: INTERMOUNTAIN SPECIALTY PHARMACY
4393 RIVERBOAT RD SUITE 101
TAYLORSVILLE, UT 84123
Pharmacy Comments
Contract Details
Approval Date
4/7/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Peter DiDio, Vice President, Controller
(208) 381-1251
Contract Pharmacy Representative
Marc Holley, Pharmacy Operations Director
(801) 284-1006
Signed By Date
4/7/2017
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