Contract Pharmacy Details

EST LLC
DSH500053 KENNEWICK GENERAL HOSPITAL

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

EST LLC

Pharmacy Address

DBA FIESTA PHARMACY
115 S 10TH AVE
PASCO, WA 99301

Pharmacy Comments

03/22/2012 updated name (was Fiesta Pharmacy LLC)

Contract Details

Approval Date

1/5/2015

Contract Begin Date

4/1/2015

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

Tamer Elsammack, Owner
(509) 545-0596

Signed By Date

1/5/2015