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LAKETOWN PHARMACY PLLC
DSH500033 SAMARITAN HOSPITAL
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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
LAKETOWN PHARMACY PLLC
Pharmacy Address
LAKETOWN PHARMACY
1550 S PIONEER WAY STE 105
MOSES LAKE, WA 98837
Pharmacy Comments
Contract Details
Approval Date
1/18/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Paul Ishizuka, CFO
(509) 793-9710
Contract Pharmacy Representative
Laketown Pharmacy
John Rackham, Owner
(509) 765-8891
Signed By Date
1/18/2017
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