Contract Pharmacy Details

WAL-MART PHARMACY 10-1876
SCH380001-02 Mid-Columbia Medical Center DBA Adventist Health Columbia Gorge

Covered Entity Details

Entity Name

Mid-Columbia Medical Center DBA Adventist Health Columbia Gorge

Subdivision Name

MID-COLUMBIA MEDICAL CENTER-WATER'S EDGE MEDICAL CLINIC - RURAL HEALTH CLINIC

Type

Sole Community Hospital

340B ID

SCH380001-02

Entity Address

551 LONE PINE BLVD
THE DALLES, OR 97058-3398

Medicare Provider Number

380001

Outpatient Facility Provider Number

383994

Participating Start Date

9/28/2010

Last Recertification Date

8/23/2024

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

1/1/2021
Agreement registered in error

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

340B Drug Pricing Program Database