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WAL-MART PHARMACY 10-1608
DSH050042 ST ELIZABETH COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
ST ELIZABETH COMMUNITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050042
Entity Address
2550 SISTER MARY COLUMBA
RED BLUFF, CA 96080
Medicare Provider Number
050042
Participating Start Date
1/1/2005
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1608
Pharmacy Address
608 LUTHER
RED BLUFF, CA 96080
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/13/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Randy Pennebaker, Senior Director of Operations
(530) 529-8235
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/15/2020
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