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RRC500002-00 PROV ST MARY MEDICAL CENTER (Active)
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Main Details
Name
PROV ST MARY MEDICAL CENTER
Subdivision Name
Providence St. Mary Medical Center
Type
Rural Referral Center
Rural
Yes
340B ID
RRC500002-00
Medicare Provider Number
500002
Additional Details
Current Program Status
Active
Registration Date
4/3/2024
Participating Start Date
7/1/2024
Participating Approval Date
4/30/2024
Last Recertification Date
8/23/2024
Contacts
Authorizing Official
Kadlec Regional Medical Center
Spencer Dwayne Harris, CFO
(509) 942-2708
Primary Contact
Providence St Mary Medical Center
Belinda Grimm, 340B Coordinator
(509) 897-2087
Addresses
Street Address
401 W POPLAR ST.
WALLA WALLA, WA 99362-2846
Billing Address
PROVIDENCE ACCOUNTS PAYABLE
P.O. BOX 696430
SAN ANTONIO, TX 78269
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating from effective date: (07/01/2020) until terminated effective date: (10/01/2022); reinstatement effective date: (07/1/2024)
04/29/2024
April 2025
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