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ADVANCED PHARMACY, LLC
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
ADVANCED PHARMACY, LLC
Pharmacy Address
ADVANCED PHARMACY
350 FEASTER ROAD
SUITE D
GREENVILLE, SC 29615-6176
Pharmacy Comments
Contract Details
Approval Date
4/15/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2016
Agreement registered in error
Contacts
Covered Entity Signing Official
Jason Gibbons, CFO
(208) 436-8153
Contract Pharmacy Representative
Gregory P. Santulli, President
(770) 339-1190 Ext: 7063
Signed By Date
4/15/2016
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