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WAL-MART PHARMACY 10-2476
DSH500049 WALLA WALLA GENERAL HOSPITAL
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Covered Entity Details
Entity Name
WALLA WALLA GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500049
Entity Address
1025 SOUTH SECOND AVE.
WALLA WALLA, WA 99362
Medicare Provider Number
500049
Participating Start Date
7/1/2006
Last Recertification Date
8/30/2016
Entity Termination Date
10/1/2017
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2476
Pharmacy Address
1700 S.E. MEADOWBROOK BLVD
COLLEGE PLACE, WA 99324
Pharmacy Comments
Contract Details
Approval Date
2/28/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2017
Contacts
Covered Entity Signing Official
Greg McCulloch, President
(209) 536-5012
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/15/2013
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