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SID'S LTC PHARMACY
CAH501331-00 Public Hospital District #1-A DBA Pullman Regional Hospital
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Covered Entity Details
Entity Name
Public Hospital District #1-A DBA Pullman Regional Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH501331-00
Entity Address
835 SE Bishop Blvd
Pullman, WA 99163
Medicare Provider Number
501331
Participating Start Date
4/1/2012
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
SID'S LTC PHARMACY
Pharmacy Address
PROFESSIONAL MALL PHARMACY, INC.
825 SE BISHOP BLVD
SUITE 301B
PULLMAN, WA 99163
Pharmacy Comments
Contract Details
Approval Date
2/25/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2017
Ownership change
Contacts
Covered Entity Signing Official
Steve Douglas Febus, CFO
(509) 336-7362
Contract Pharmacy Representative
Sidney H. Pierson, Owner/Pharmacist
(509) 332-4608
Signed By Date
1/8/2013
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