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WAL-MART CENTRAL FILL 10-2670
CAH131311-00 ST. LUKE'S ELMORE MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. LUKE'S ELMORE MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131311-00
Entity Address
895 N. SIXTH EAST
MOUNTAIN HOME, ID 83647
Medicare Provider Number
131311
Participating Start Date
1/1/2018
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART CENTRAL FILL 10-2670
Pharmacy Address
608 SPRING HILL DR # 3 SUITE 300
SPRING, TX 77386
Pharmacy Comments
Contract Details
Approval Date
1/12/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Peter DiDio, Vice President, Controller
(208) 381-1251
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/12/2018
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