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WAL-MART PHARMACY 10-1876
SCH380001-01 MID-COLUMBIA MEDICAL CENTER
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Covered Entity Details
Entity Name
MID-COLUMBIA MEDICAL CENTER
Subdivision Name
MID-COLUMBIA MEDICAL CENTER- RIVERVIEW CLINIC RURAL HEALTH CLINIC
Type
Sole Community Hospital
340B ID
SCH380001-01
Entity Address
1825 E 19TH STREET
THE DALLES, OR 97058
Medicare Provider Number
380001
Outpatient Facility Provider Number
383993
Participating Start Date
9/28/2010
Last Recertification Date
8/30/2016
Entity Termination Date
4/1/2017
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1876
Pharmacy Address
2700 WASCO AVENUE
HOOD RIVER, OR 97031
Pharmacy Comments
Contract Details
Approval Date
9/21/2012
Contract Begin Date
9/21/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Contacts
Covered Entity Signing Official
DONALD ARBON, V.P. FINANCE/CFO
(541) 296-7524
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/7/2012
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