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WAL-MART PHARMACY 10-2403
DSH500079 GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500079
Entity Address
401 15th Avenue SE
PUYALLUP, WA 98372
Medicare Provider Number
500079
Participating Start Date
1/1/2022
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2403
Pharmacy Address
310 31ST AVE SE
PUYALLUP, WA 98374-1232
Pharmacy Comments
Contract Details
Approval Date
4/6/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Timothy Wayne Lynch, Sr. VP, Chief Administrative Officer
(253) 403-2824
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/6/2023
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