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EST LLC
CAH501337-00 LOURDES MEDICAL CENTER
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Covered Entity Details
Entity Name
LOURDES MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH501337-00
Entity Address
520 N 4TH AVENUE
PASCO, WA 99301
Medicare Provider Number
501337
Participating Start Date
1/1/2011
Last Recertification Date
11/15/2017
Entity Termination Date
10/1/2018
Pharmacy Details
Pharmacy Name
EST LLC
Pharmacy Address
DBA FIESTA PHARMACY
115 S 10TH AVE
PASCO, WA 99301
Pharmacy Comments
03/22/2012 updated name (was Fiesta Pharmacy LLC)
Contract Details
Approval Date
3/13/2012
Contract Begin Date
3/13/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Tracy Sue Clark, Director of Pharmacy
(509) 546-2298
Contract Pharmacy Representative
Tamer Elsammack, Owner
(509) 545-0596
Signed By Date
2/24/2012
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