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WAL-MART PHARMACY 10-2196
RRC500072-00 OLYMPIC MEDICAL CENTER
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Covered Entity Details
Entity Name
OLYMPIC MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC500072-00
Entity Address
939 CAROLINE STREET
PORT ANGELES, WA 98362
Medicare Provider Number
500072
Participating Start Date
10/1/2015
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2196
Pharmacy Address
3411 E KOLONELS WAY
PORT ANGELES, WA 98362-9089
Pharmacy Comments
Contract Details
Approval Date
10/13/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/19/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Darryl Wolfe, Chief Executive Officer
(360) 417-7705
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/13/2017
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