Contract Pharmacy Details

CAREMARK, L.L.C.
RRC500002-00 PROV ST MARY MEDICAL CENTER

Covered Entity Details

Entity Name

PROV ST MARY MEDICAL CENTER

Subdivision Name

Providence St. Mary Medical Center

Type

Rural Referral Center

340B ID

RRC500002-00

Entity Address

401 W POPLAR ST.
WALLA WALLA, WA 99362-2846

Medicare Provider Number

500002

Participating Start Date

7/1/2024

Last Recertification Date

8/23/2024

Pharmacy Details

Pharmacy Name

CAREMARK, L.L.C.

Pharmacy Address

DBA CVS/SPECIALTY OR CARELONRX SPECIALTY
7251 S. EASTERN AVE.
LAS VEGAS, NV 89119

Pharmacy Comments

Contract Details

Approval Date

10/6/2021

Contract Begin Date

1/1/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2022
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Susan Blackburn, CHIEF EXECUTIVE
(509) 897-2290

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

10/6/2021

340B Drug Pricing Program Database