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WAL-MART PHARMACY 10-3705
DSH500079 GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500079
Entity Address
401 15th Avenue SE
PUYALLUP, WA 98372
Medicare Provider Number
500079
Participating Start Date
1/1/2022
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3705
Pharmacy Address
17100 STATE ROUTE 507 SE
YELM, WA 98597
Pharmacy Comments
Contract Details
Approval Date
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Florence Chang, President
(253) 403-7355
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/15/2019
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