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HAWAII PACIFIC HEALTH SPECIALTY PHARMACY
RRC120026-00 PALI MOMI MEDICAL CENTER
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Covered Entity Details
Entity Name
PALI MOMI MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC120026-00
Entity Address
98-1079 MOANALUA ROAD
AIEA, HI 96701
Medicare Provider Number
120026
Participating Start Date
11/9/2020
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
HAWAII PACIFIC HEALTH SPECIALTY PHARMACY
Pharmacy Address
3375 KOAPAKA STREET
STE H400
HONOLULU, HI 96819
Pharmacy Comments
Contract Details
Approval Date
4/7/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David E Stumbaugh, VP, Supply Chain Management and Pharmacy
(808) 522-6946
Contract Pharmacy Representative
Hawaii Pacific Health
Shannon Terayama, Director, Outpatient & Ambulatory Pharmacy Services
(808) 404-8259
Signed By Date
4/7/2023
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