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R & J PHARMACY, INC.
FQHC638535A Shoshone-Bannock Tribes Health & Human Services Community Health Center
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Covered Entity Details
Entity Name
Shoshone-Bannock Tribes Health & Human Services Community Health Center
Subdivision Name
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638535A
Entity Address
70 Navajo Drive
Fort Hall, ID 83203
Grant Number
Participating Start Date
1/1/2016
Last Recertification Date
2/23/2017
Entity Termination Date
4/1/2017
Pharmacy Details
Pharmacy Name
R & J PHARMACY, INC.
Pharmacy Address
PHARMACY SHOP
69 N PINE ST
BLACKFOOT, ID 83221-2053
Pharmacy Comments
Contract Details
Approval Date
11/2/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Contacts
Covered Entity Signing Official
Steve Hagler, Tribal CFO
(208) 478-3843
Contract Pharmacy Representative
Rob Miller, Owner
(208) 785-3510
Signed By Date
11/2/2015
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