Contract Pharmacy Details

ALBERTSONS LLC
CAH131311-00 ST. LUKE'S ELMORE MEDICAL CENTER

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

ALBERTSONS LLC

Pharmacy Address

SAV-ON PHARMACY #165
528 NORTH MAIN ST
MOUNTAIN HOME, ID 83647

Pharmacy Comments

Contract Details

Approval Date

1/15/2018

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

Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304

Signed By Date

1/15/2018

340B Drug Pricing Program Database