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WAL-MART PHARMACY 10-3260
DSH500033 SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500033
Entity Address
801 E WHEELER ROAD
MOSES LAKE, WA 98837
Medicare Provider Number
500033
Participating Start Date
1/1/2009
Last Recertification Date
8/20/2019
Entity Termination Date
7/1/2020
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3260
Pharmacy Address
1399 NAT WASHINGTON WAY
EPHRATA, WA 98823
Pharmacy Comments
Contract Details
Approval Date
4/10/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Alexander Town, Chief Financial Officer
(509) 793-9710
Contract Pharmacy Representative
Samaritan Healthcare
Lloyd Stevers, Pharmacy Director
(509) 765-5606
Signed By Date
4/10/2019
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