Contract Pharmacy Details

THRIFTY PAYLESS, INC.
DSH500049 WALLA WALLA GENERAL HOSPITAL

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

THRIFTY PAYLESS, INC.

Pharmacy Address

RITE AID #5399
105 SOUTHWEST SECOND AVENUE
MILTON-FREEWATER, OR 97862

Pharmacy Comments

Contract Details

Approval Date

10/18/2016

Contract Begin Date

1/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2017

Contacts

Covered Entity Signing Official

BRIAN ANDERSON, VICE PRESIDENT FINANCE
(509) 527-8201

Contract Pharmacy Representative

Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968

Signed By Date

10/18/2016

340B Drug Pricing Program Database