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SHOPKO PHARMACY #2073
DSH500036 YAKIMA VALLEY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
YAKIMA VALLEY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500036
Entity Address
2811 TIETON DR.
YAKIMA, WA 98902
Medicare Provider Number
500036
Participating Start Date
12/1/1992
Last Recertification Date
8/17/2024
Pharmacy Details
Pharmacy Name
SHOPKO PHARMACY #2073
Pharmacy Address
2530 RUDKIN ROAD
UNION GAP, WA 98903
Pharmacy Comments
Contract Details
Approval Date
10/17/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/11/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Timothy Reed, CFO
(509) 574-5965
Contract Pharmacy Representative
Shopko Pharmacy
Debi Danbury, 340B Program Manager
(920) 429-7613
Signed By Date
10/17/2017
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