Contract Pharmacy Details

SOUTHGATE PHARMACY
DSH500033 SAMARITAN HOSPITAL

Covered Entity Details

Entity Name

SAMARITAN HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH500033

Entity Address

801 E WHEELER ROAD
MOSES LAKE, WA 98837

Medicare Provider Number

500033

Participating Start Date

1/1/2009

Last Recertification Date

8/20/2019

Entity Termination Date

7/1/2020

Pharmacy Details

Pharmacy Name

SOUTHGATE PHARMACY

Pharmacy Address

2709 W BROADWAY AVE
MOSES LAKE, WA 98837-2904

Pharmacy Comments

Contract Details

Approval Date

7/5/2012

Contract Begin Date

7/5/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2020
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Thomas J. Legel, CFO
(509) 793-9710

Contract Pharmacy Representative

Southgate Pharmacy
Lateef Olaniyan, Owner/President
(509) 765-9332

Signed By Date

6/25/2012

340B Drug Pricing Program Database