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WAL-MART PHARMACY 10-1772
CAH381309-00 LAKE DISTRICT HOSPITAL
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Covered Entity Details
Entity Name
LAKE DISTRICT HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH381309-00
Entity Address
700 SOUTH J ST.
LAKEVIEW, OR 97630
Medicare Provider Number
381309
Participating Start Date
9/28/2010
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1772
Pharmacy Address
3600 WASHBURN WAY
KLAMATH FALLS, OR 97603
Pharmacy Comments
Contract Details
Approval Date
10/17/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/31/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Charles Tveit, Chief Executive Officer
(541) 947-2114 Ext: 221
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/17/2016
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