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WAL-MART PHARMACY 10-3261
DSH500053 KENNEWICK GENERAL HOSPITAL
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Covered Entity Details
Entity Name
KENNEWICK GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500053
Entity Address
900 S AUBURN STREET
KENNEWICK, WA 99336
Medicare Provider Number
500053
Participating Start Date
10/1/2004
Last Recertification Date
12/6/2017
Entity Termination Date
10/1/2018
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3261
Pharmacy Address
2801 DUPORTAIL STREET
RICHLAND, WA 99352
Pharmacy Comments
Contract Details
Approval Date
10/14/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Tony Sudduth, CFO
(509) 221-5349
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
10/14/2014
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