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WALLACE DRUG
CAH131304-00 Power County Hospital District
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Covered Entity Details
Entity Name
Power County Hospital District
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131304-00
Entity Address
510 Roosevelt ST
American Falls, ID 83211
Medicare Provider Number
131304
Participating Start Date
7/1/2013
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WALLACE DRUG
Pharmacy Address
44 S MAIN ST.
BOX 841
ABERDEEN, ID 83210
Pharmacy Comments
Contract Details
Approval Date
6/12/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shauna Croft, CFO
(208) 226-3200 Ext: 128
Contract Pharmacy Representative
Dwight Wallace, Owner
(208) 397-4540
Signed By Date
4/15/2013
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