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BENGAL PHARMACY - ARCO
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 - ARCO
Pharmacy Address
DBA LOST RIVER DRUGS - LIMITED SERVICE L
REMOTE PHARMACY
551 HIGHLAND DR
ARCO, ID 83213-8321
Pharmacy Comments
Contract Details
Approval Date
7/15/2014
Contract Begin Date
8/1/2014
Carve-In Effective Date
Contract Comments
08/01/2014 Immediate begin date authorized
Contract Termination Date
Termination Reason
6/30/2021
Ownership change
Contacts
Covered Entity Signing Official
Bradley Huerta, Administrator / CEO
(208) 252-7654 Ext: 701
Contract Pharmacy Representative
Karri K. Jardine, CPht
(208) 527-8206
Signed By Date
7/15/2014
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