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THE BROADWAY PHARMACY
RRC270014-00 ST PATRICK HOSPITAL
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Covered Entity Details
Entity Name
ST PATRICK HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC270014-00
Entity Address
500 W. BROADWAY ST
MISSOULA, MT 59802
Medicare Provider Number
270014
Participating Start Date
7/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
THE BROADWAY PHARMACY
Pharmacy Address
CARON CORPORATION
500 W BROADWAY
MISSOULA, MT 59802
Pharmacy Comments
Contract Details
Approval Date
5/11/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kirk Bodlovic, Chief Operating Officer
(406) 327-1740
Contract Pharmacy Representative
Providence St. Patrick Hospital
Jason Nickisch, Director of Pharmacy
(406) 329-5720
Signed By Date
4/10/2018
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