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WAL-MART PHARMACY 10-1889
CAH381321-00 Grande Ronde Hospital, Inc.
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Covered Entity Details
Entity Name
Grande Ronde Hospital, Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH381321-00
Entity Address
900 Sunset Drive
La Grande, OR 97850
Medicare Provider Number
381321
Participating Start Date
4/1/2013
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1889
Pharmacy Address
11619 ISLAND AVENUE
ISLAND CITY, OR 97850
Pharmacy Comments
Contract Details
Approval Date
4/2/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Wade E. Weis, Sr. Director of Finance/CFO
(541) 963-1463
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/2/2015
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