Contract Pharmacy Details

SHOPKO PHARMACY #2795
CAH131305-00 STEELE MEMORIAL MEDICAL CENTER

Covered Entity Details

Entity Name

STEELE MEMORIAL MEDICAL CENTER

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH131305-00

Entity Address

203 S. DAISY STREET
SALMON, ID 83467

Medicare Provider Number

131305

Participating Start Date

10/1/2015

Last Recertification Date

8/30/2024

Pharmacy Details

Pharmacy Name

SHOPKO PHARMACY #2795

Pharmacy Address

1026 S CHALLIS ST
SALMON, ID 83467

Pharmacy Comments

Contract Details

Approval Date

9/1/2015

Contract Begin Date

10/1/2015

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/31/2017
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

James Allen Peterson, Chief Financial Officer
(208) 756-5618

Contract Pharmacy Representative

ShopKo
Lorie Neumann, Contracting & Compliance
(920) 429-4726

Signed By Date

9/1/2015

340B Drug Pricing Program Database