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WAL-MART PHARMACY 10-2861
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 10-2861
Pharmacy Address
7319 WEST STATE STREET
PO BOX 1407
GARDEN CITY, ID 83714
Pharmacy Comments
Contract Details
Approval Date
4/10/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kenneth Fry, VP Finance
(208) 367-3445
Contract Pharmacy Representative
Kathi Phelps, Manager Contracting & Channell Management
(479) 899-8830
Signed By Date
4/10/2013
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