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SHIVA LLC
CAH501312-00 PROSSER MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
PROSSER MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH501312-00
Entity Address
200 Prosser Health Drive
PROSSER, WA 99350
Medicare Provider Number
501312
Participating Start Date
4/1/2019
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
SHIVA LLC
Pharmacy Address
PROSSER PHARMACY
354 CHARDONNAY AVE STE 5
PROSSER, WA 99350-9545
Pharmacy Comments
Contract Details
Approval Date
7/12/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David Eugene Rollins, Chief Financial Officer
(509) 786-6605 Ext: 5097866605
Contract Pharmacy Representative
Prosser Pharmacy
Eddin Loulou, Owner
(206) 602-7575
Signed By Date
7/12/2024
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