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LONGS DRUG STORES CALIFORNIA, L.L.C.
DSH120014 WILCOX MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
WILCOX MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH120014
Entity Address
3-3420 KUHIO HIGHWAY
LIHUE, HI 96766
Medicare Provider Number
120014
Participating Start Date
10/1/2022
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
LONGS DRUG STORES CALIFORNIA, L.L.C.
Pharmacy Address
DBA LONGS DRUGS #10474
2829 ALA KALANIKAUMAUKA STREET, SUITE M-
KOLOA, HI 96756
Pharmacy Comments
Contract Details
Approval Date
7/6/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JEN CHAHANOVICH, CEO
(808) 245-1100 Ext: 1103
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/1/2022
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