Contract Pharmacy Details

ESTM INC
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

ESTM INC

Pharmacy Address

RELIANCE PHARMACY
133 N ELY ST STE C1
KENNEWICK, WA 99336

Pharmacy Comments

Contract Details

Approval Date

4/13/2016

Contract Begin Date

7/1/2016

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

4/13/2016