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KO'OLAULOA PHARMACY
CAH121304-00 KAHUKU MEDICAL CENTER
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Covered Entity Details
Entity Name
KAHUKU MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH121304-00
Entity Address
56-117 PUALALEA ST.
KAHUKU, HI 96731
Medicare Provider Number
121304
Participating Start Date
1/1/2018
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
KO'OLAULOA PHARMACY
Pharmacy Address
686206
56-119 PUALALEA ST
KAHUKU, HI 96731
Pharmacy Comments
Contract Details
Approval Date
4/21/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/17/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Alan MacPhee, CEO
(808) 293-6222
Contract Pharmacy Representative
Ko'olauloa Health Center
Allen John Bagalso, Director of Pharmacy
(808) 293-9514
Signed By Date
4/21/2022
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