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WAL-MART.PHARMACY 10-4394
CAH501305-00 Lincoln County Public Hospital District No. 3
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Covered Entity Details
Entity Name
Lincoln County Public Hospital District No. 3
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH501305-00
Entity Address
10 Nicholls St
Davenport, WA 99122
Medicare Provider Number
501305
Participating Start Date
7/1/2012
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WAL-MART.PHARMACY 10-4394
Pharmacy Address
1221 S. HAYFORD RD.
SPOKANE, WA 99224
Pharmacy Comments
Contract Details
Approval Date
7/1/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tyson Lacy, CEO
(509) 725-2979 Ext: 1168
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/1/2016
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