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SMITHS FOOD& DRUG CENTERS
CAH131319-00 Minidoka Memorial Hospital
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Covered Entity Details
Entity Name
Minidoka Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131319-00
Entity Address
1224 8th St
Rupert, ID 83350
Medicare Provider Number
131319
Participating Start Date
7/1/2012
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
SMITHS FOOD& DRUG CENTERS
Pharmacy Address
SMITHS PHARMACY #123
937 E MAIN STREET
BURLEY, ID 83318
Pharmacy Comments
Contract Details
Approval Date
8/29/2012
Contract Begin Date
8/29/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jason Gibbons, CFO
(208) 436-8153
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
8/21/2012
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