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SHOPKO PHARMACY #2073
CAH501333-00 KITTITAS COUNTY PUBLIC HOSPITAL DISTRICT #1
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Covered Entity Details
Entity Name
KITTITAS COUNTY PUBLIC HOSPITAL DISTRICT #1
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH501333-00
Entity Address
603 S CHESTNUT ST
ELLENSBURG, WA 98926
Medicare Provider Number
501333
Participating Start Date
8/25/2010
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
SHOPKO PHARMACY #2073
Pharmacy Address
2530 RUDKIN ROAD
UNION GAP, WA 98903
Pharmacy Comments
Contract Details
Approval Date
1/12/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/2/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rhonda Holden, Chief Ancillary Officer
(509) 962-7320
Contract Pharmacy Representative
Kittitas Valley Healthcare Hospital
Nasser Basmeh, Director of Pharmacy
(509) 962-7420
Signed By Date
1/12/2018
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