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BENGAL PHARMACY
HV24732 Idaho State Univsersity
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Covered Entity Details
Entity Name
Idaho State Univsersity
Subdivision Name
Family Medicine
Type
Ryan White Part C
340B ID
HV24732
Entity Address
1651 Alvin Ricken Drive
Suite 116
Pocatello, ID 83209-8046
Grant Number
H76HA24732
Participating Start Date
1/1/2013
Last Recertification Date
2/23/2017
Entity Termination Date
4/1/2017
Pharmacy Details
Pharmacy Name
BENGAL PHARMACY
Pharmacy Address
990 SOUTH 8TH AVE
POCATELLO, ID 83209-0001
Pharmacy Comments
Contract Details
Approval Date
1/22/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Contacts
Covered Entity Signing Official
Cornelis Van Der Schyf, VP Research and Grad SChool
(208) 282-2592
Contract Pharmacy Representative
Rebecca Hoover, Director of Pharmacy
(208) 282-6064
Signed By Date
1/22/2014
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