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WAL-MART PHARMACY 10-2607
CAH271325-00 St. Luke Community Hospital & Nursing Home
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Covered Entity Details
Entity Name
St. Luke Community Hospital & Nursing Home
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH271325-00
Entity Address
107 6th Avenue SW
Ronan, MT 59864
Medicare Provider Number
271325
Participating Start Date
10/1/2013
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2607
Pharmacy Address
36318 MEMORY LANE
POLSON, MT 59860
Pharmacy Comments
Contract Details
Approval Date
4/15/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Paul Soukup, CFO
(406) 676-4441 Ext: 291
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/15/2014
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