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LIHUE PROFESSIONAL PHARMACY
SCH120014-00 WILCOX MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
WILCOX MEMORIAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH120014-00
Entity Address
3-3420 KUHIO HWY
LIHUE, HI 96766
Medicare Provider Number
120014
Participating Start Date
9/21/2010
Last Recertification Date
9/10/2021
Entity Termination Date
10/1/2022
Pharmacy Details
Pharmacy Name
LIHUE PROFESSIONAL PHARMACY
Pharmacy Address
3-3420B KUHIO HWY STE 101
LIHUE, HI 96766-1096
Pharmacy Comments
Contract Details
Approval Date
1/15/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/8/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JEN CHAHANOVICH, CEO
(808) 245-1100 Ext: 1103
Contract Pharmacy Representative
Lihue Professional Pharmacy
Kevin Glick, President
(808) 246-9100
Signed By Date
1/15/2019
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