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PRIME THERAPEUTICS SPECIALTY PHARMACY LL
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
PRIME THERAPEUTICS SPECIALTY PHARMACY LL
Pharmacy Address
ALLIANCERX WALGREENS PRIME #16568
2354 COMMERCE PARK DRIVE
SUITE 100
ORLANDO, FL 32819-9992
Pharmacy Comments
Contract Details
Approval Date
7/18/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/14/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Susan Blackburn, CHIEF EXECUTIVE
(509) 897-2290
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/18/2017
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