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OLIVE BRANCH PHARMACY
CAH381306-01 Wallowa County Health Care District DBA Wallowa Memorial Hospital
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Covered Entity Details
Entity Name
Wallowa County Health Care District DBA Wallowa Memorial Hospital
Subdivision Name
Wallowa Memorial Medical Clinic - Enterprise
Type
Critical Access Hospital
340B ID
CAH381306-01
Entity Address
603 Medical Parkway
Enterprise, OR 97828
Medicare Provider Number
381306
Outpatient Facility Provider Number
Participating Start Date
1/1/2016
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OLIVE BRANCH PHARMACY
Pharmacy Address
RED CROSS UNITED DRUG INC
306 W. NORTH ST.
ENTERPRISE, OR 97828
Pharmacy Comments
Contract Details
Approval Date
10/17/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/9/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Joe Wanner, Chief Financial Officer
(541) 426-5460
Contract Pharmacy Representative
Bob Coulter, Owner
(541) 805-5231
Signed By Date
10/17/2016
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