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WALGREEN CO.
CAH501332-00 TRI-STATE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
TRI-STATE MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH501332-00
Entity Address
1221 HIGHLAND AVE
CLARKSTON, WA 99403
Medicare Provider Number
501332
Participating Start Date
9/30/2010
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 02679
2102 NEZ PERCE DR
LEWISTON, ID 83501
Pharmacy Comments
Contract Details
Approval Date
4/17/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
ALEX TOWN, CFO
(509) 758-4667
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/17/2015
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