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CYSTIC FIBROSIS SERVICES, LLC
RRC500002-00 PROV ST MARY MEDICAL CENTER
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Covered Entity Details
Entity Name
PROV ST MARY MEDICAL CENTER
Subdivision Name
Providence St. Mary Medical Center
Type
Rural Referral Center
340B ID
RRC500002-00
Entity Address
401 W POPLAR ST.
WALLA WALLA, WA 99362-2846
Medicare Provider Number
500002
Participating Start Date
7/1/2024
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
4/30/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Spencer Dwayne Harris, CFO
(509) 942-2708
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/12/2024
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