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NORTH CANYON MEDICAL CENTER, INC.
CAH131302-00 NORTH CANYON MEDICAL CENTER
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Covered Entity Details
Entity Name
NORTH CANYON MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131302-00
Entity Address
267 NORTH CANYON DRIVE
GOODING, ID 83330
Medicare Provider Number
131302
Participating Start Date
10/1/2017
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
NORTH CANYON MEDICAL CENTER, INC.
Pharmacy Address
267 N CANYON DR
GOODING, ID 83330-5500
Pharmacy Comments
Contract Details
Approval Date
8/9/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/18/2019
Agreement registered in error
Contacts
Covered Entity Signing Official
Sara DeMoe, Controller
(208) 934-4433 Ext: 1201
Contract Pharmacy Representative
North Canyon Medical Center INC.
Tyson Frodin, Director of Pharmacy
(208) 934-4433 Ext: 1195
Signed By Date
8/9/2017
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