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ALBERTSONS LLC
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
ALBERTSONS LLC
Pharmacy Address
SAV-ON PHARMACY #103
415 CLEVELAND BLVD
CALDWELL, ID 83605
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
12/31/2019
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
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