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WAL-MART CENTRAL FILL 10-2670
CAH021311-00 PEACEHEALTH D/B/A KETCHIKAN MEDICAL CENTER
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Covered Entity Details
Entity Name
PEACEHEALTH D/B/A KETCHIKAN MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH021311-00
Entity Address
3100 TONGASS AVE
KETCHIKAN, AK 99901
Medicare Provider Number
021311
Participating Start Date
7/1/2011
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WAL-MART CENTRAL FILL 10-2670
Pharmacy Address
608 SPRING HILL DR # 3 SUITE 300
SPRING, TX 77386
Pharmacy Comments
Contract Details
Approval Date
1/8/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Krista N Touros, CFO
(360) 788-6754 Ext: 6754
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/8/2021
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