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WAL-MART PHARMACY 10-5315
RRC380014-00 GOOD SAMARITAN HOSPITAL CORVALLIS
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Covered Entity Details
Entity Name
GOOD SAMARITAN HOSPITAL CORVALLIS
Subdivision Name
Type
Rural Referral Center
340B ID
RRC380014-00
Entity Address
3600 NW SAMARITAN DRIVE
CORVALLIS, OR 97330
Medicare Provider Number
380014
Participating Start Date
10/1/2018
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
7/16/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Daniel Smith, VP Finance/CFO
(541) 768-5390
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/16/2019
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