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WAL-MART PHARMACY 10-5315
CAH381308-00 Salem Health West Valley
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Covered Entity Details
Entity Name
Salem Health West Valley
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH381308-00
Entity Address
525 SE WASHINGTON STREET
DALLAS, OR 97338-0378
Medicare Provider Number
381308
Participating Start Date
1/1/2016
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
4/20/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/29/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Bruce Rodgers, Chief Administrative Officer
(503) 623-7323
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/20/2017
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