Contract Pharmacy Details

ALBERTSONS LLC
DSH130007 Saint Alphonsus Regional Medical Center

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

ALBERTSONS LLC

Pharmacy Address

SAV-ON PHARMACY #130
911 MAIN ST. NORTH
HAILEY, ID 83333

Pharmacy Comments

Contract Details

Approval Date

1/16/2017

Contract Begin Date

4/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

3/8/2018
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Kenneth Fry, VP Finance
(208) 367-3445

Contract Pharmacy Representative

Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304

Signed By Date

1/16/2017

340B Drug Pricing Program Database