Contract Pharmacy Details

SHOPKO PHARMACY #2794
CAH501320-00 QUINCY VALLEY MEDICAL CENTER

Covered Entity Details

Entity Name

QUINCY VALLEY MEDICAL CENTER

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH501320-00

Entity Address

908 10TH AVENUE SW
QUINCY, WA 98848

Medicare Provider Number

501320

Participating Start Date

4/1/2017

Last Recertification Date

11/17/2017

Entity Termination Date

10/1/2018

Pharmacy Details

Pharmacy Name

SHOPKO PHARMACY #2794

Pharmacy Address

814 13TH AVENUE SW
QUINCY, WA 98848

Pharmacy Comments

Contract Details

Approval Date

3/20/2017

Contract Begin Date

4/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2018
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Marissa Villela, CNO
(509) 787-3531 Ext: 5398

Contract Pharmacy Representative

ShopKo
Lorie Neumann, Contracting & Compliance
(920) 429-4726

Signed By Date

3/20/2017

340B Drug Pricing Program Database