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BENGAL PHARMACY
CAH131324-00 Lost Rivers District Hospital
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Covered Entity Details
Entity Name
Lost Rivers District Hospital
Subdivision Name
Lost Rivers Medical Center
Type
Critical Access Hospital
340B ID
CAH131324-00
Entity Address
551 Highland Drive
Arco, ID 83213
Medicare Provider Number
131324
Participating Start Date
7/1/2013
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
BENGAL PHARMACY
Pharmacy Address
990 SOUTH 8TH AVE
POCATELLO, ID 83209-0001
Pharmacy Comments
Contract Details
Approval Date
1/21/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Bradley Huerta, Administrator / CEO
(208) 252-7654 Ext: 701
Contract Pharmacy Representative
Kerry Casperson, President
(208) 282-3407
Signed By Date
1/21/2014
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