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SHOPKO PHARMACY #2556
CAH501312-00 PROSSER MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
PROSSER MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH501312-00
Entity Address
200 Prosser Health Drive
PROSSER, WA 99350
Medicare Provider Number
501312
Participating Start Date
4/1/2019
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
SHOPKO PHARMACY #2556
Pharmacy Address
471 WINE COUNTRY RD
PROSSER, WA 99350
Pharmacy Comments
Contract Details
Approval Date
7/18/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
TIM COOPER, CFO
(509) 786-2222 Ext: 6051
Contract Pharmacy Representative
ShopKo
Lorie Neumann, Contracting & Compliance
(920) 429-4726
Signed By Date
7/18/2016
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