Contract Pharmacy Details

WAL-MART PHARMACY 10-2595
DSH500003 SKAGIT VALLEY HOSPITAL

Covered Entity Details

Entity Name

SKAGIT VALLEY HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH500003

Entity Address

1415 EAST KINCAID
MOUNT VERNON, WA 98274-4126

Medicare Provider Number

500003

Participating Start Date

7/1/2006

Last Recertification Date

8/21/2024

Pharmacy Details

Pharmacy Name

WAL-MART PHARMACY 10-2595

Pharmacy Address

8924 QUILCEDA BLVD.
TULALIP, WA 98271

Pharmacy Comments

Contract Details

Approval Date

7/13/2020

Contract Begin Date

8/4/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

12/1/2023
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Paul Ishizuka, CFO
(360) 814-5838

Contract Pharmacy Representative

Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498

Signed By Date

7/13/2020

340B Drug Pricing Program Database