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CVS/SPECIALTY OR CARELONRX SPECIALTY PHA
DSH500002 PROV ST MARY MEDICAL CENTER
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Covered Entity Details
Entity Name
PROV ST MARY MEDICAL CENTER
Subdivision Name
Providence St. Mary Medical Center
Type
Disproportionate Share Hospital
340B ID
DSH500002
Entity Address
401 W POPLAR ST.
WALLA WALLA, WA 99362-2846
Medicare Provider Number
500002
Participating Start Date
10/1/2022
Last Recertification Date
8/30/2023
Entity Termination Date
7/1/2024
Pharmacy Details
Pharmacy Name
CVS/SPECIALTY OR CARELONRX SPECIALTY PHA
Pharmacy Address
CAREMARK, LLC
1001 SPINKS ROAD, STE 280
FLOWER MOUND, TX 75028
Pharmacy Comments
Contract Details
Approval Date
8/31/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Spencer Dwayne Harris, CFO
(509) 942-2708
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/8/2022
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