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WASHINGTON CVS PHARMACY, L.L.C.
DSH500139 CAPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
CAPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500139
Entity Address
3900 CAPITAL MALL DRIVE SW
OLYMPIA, WA 98502
Medicare Provider Number
500139
Participating Start Date
7/1/2022
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
WASHINGTON CVS PHARMACY, L.L.C.
Pharmacy Address
CVS/PHARMACY # 11023
9400 GRAVELLY LAKE DR SW
LAKEWOOD, WA 98499
Pharmacy Comments
Contract Details
Approval Date
6/7/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Florence Chang, President
(253) 403-7355
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/15/2022
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