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WAL-MART PHARMACY 10-2781
DSH130007 Saint Alphonsus Regional Medical Center
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Covered Entity Details
Entity Name
Saint Alphonsus Regional Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH130007
Entity Address
1055 N. Curtis Rd.
Boise, ID 83706
Medicare Provider Number
130007
Participating Start Date
4/1/2012
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2781
Pharmacy Address
2100 12TH AVENUE ROAD
NAMPA, ID 83686
Pharmacy Comments
Contract Details
Approval Date
11/9/2012
Contract Begin Date
11/9/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kenneth Fry, VP Finance
(208) 367-3445
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/26/2012
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