Contract Pharmacy Details

BENGAL PHARMACY
CAH131327-00 Gritman Medical Center

Covered Entity Details

Entity Name

Gritman Medical Center

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH131327-00

Entity Address

700 S Main St
Moscow, ID 83843

Medicare Provider Number

131327

Participating Start Date

7/1/2013

Last Recertification Date

8/28/2024

Pharmacy Details

Pharmacy Name

BENGAL PHARMACY

Pharmacy Address

990 SOUTH 8TH AVE
POCATELLO, ID 83209-0001

Pharmacy Comments

Contract Details

Approval Date

7/18/2017

Contract Begin Date

10/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

2/2/2018
Agreement registered in error

Contacts

Covered Entity Signing Official

Kara Besst, CEO
(208) 883-2220

Contract Pharmacy Representative

Bret Jacobson, 340B Rep
(208) 282-6150

Signed By Date

7/18/2017