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HAWAII PACIFIC HEALTH SPECIALTY PHARMACY
DSH120014 WILCOX MEMORIAL HOSPTIAL
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Covered Entity Details
Entity Name
WILCOX MEMORIAL HOSPTIAL
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
HAWAII PACIFIC HEALTH SPECIALTY PHARMACY
Pharmacy Address
3375 KOAPAKA STREET
STE H400
HONOLULU, HI 96819
Pharmacy Comments
Contract Details
Approval Date
4/12/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JEN CHAHANOVICH, CEO
(808) 245-1100 Ext: 1103
Contract Pharmacy Representative
Hawaii Pacific Health
Shannon Terayama, Director, Outpatient & Ambulatory Pharmacy Services
(808) 404-8259
Signed By Date
4/12/2023
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