Covered Entity Details

DSH500003 SKAGIT VALLEY HOSPITAL (Active) - information as of 6/9/2025 11:04:11 PM

Main Details

Name

SKAGIT VALLEY HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH500003

Medicare Provider Number

500003

Additional Details

Current Program Status

Active

Registration Date

5/2/2006

Participating Start Date

7/1/2006

Participating Approval Date

5/3/2006

Last Recertification Date

8/21/2024

Contacts

Authorizing Official

Public Hospital District No. 1, Skagit County, dba Skagit Regional Health
Tamara L Cesena, Chief Financial Officer
(360) 445-8512

Primary Contact

Skagit Valley Hospital
Alma K Martinez, 340B Program Manager
(360) 814-5001

Addresses

Street Address

1415 EAST KINCAID
MOUNT VERNON, WA 98274-4126

Billing Address

Skagit Valley Hospital
PO Box 1376
Mount Vernon, WA 98273

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
9/4/2007- DOC RECD TO CONFIRM ELIG DSH ADJ %	09/10/2007

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
WA	3323300,7105307	1023332749,1508932427,1053357244

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACARIAHEALTH PHARMACY #11, INC	1311 W SAM HOUSTON PKWY N STE 130		HOUSTON	TX	77043-4015	10/25/2018	01/01/2019	12/16/2019	12/16/2019
Contract Detail	ACARIAHEALTH PHARMACY #11, INC	1311 W SAM HOUSTON PKWY N STE 130		HOUSTON	TX	77043-4015	01/14/2022	04/01/2022	12/04/2023	12/04/2023
Contract Detail	ACARIAHEALTH PHARMACY #14, INC.	4151 E COMMERCE WAY # 1041		SACRAMENTO	CA	95834-9679	01/26/2018	04/01/2018	12/16/2019	12/16/2019
Contract Detail	ACARIAHEALTH PHARMACY #14, INC.	4151 E COMMERCE WAY # 1041		SACRAMENTO	CA	95834-9679	01/14/2022	04/01/2022	12/04/2023	12/04/2023
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	07/18/2017	10/01/2017		10/01/2017
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/18/2017	10/01/2017	04/29/2024	06/05/2024
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	07/18/2017	10/01/2017		10/01/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/18/2017	10/01/2017	04/29/2024	06/05/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	07/18/2017	10/01/2017	07/24/2018	09/20/2018
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	07/18/2017	10/01/2017	07/24/2018	09/20/2018
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	01/13/2023	04/01/2023		04/01/2023
Contract Detail	ALBERTSON'S LLC	SAV-ON PHARMACY #471	301 MARYSVILLE MALL #60	MARYSVILLE	WA	98270	07/13/2016	10/01/2016	03/21/2022	03/29/2022
Contract Detail	ARDON HEALTH, LLC	11835 NE GLENN WIDING DR		PORTLAND	OR	97220-9057	10/15/2019	01/01/2020	09/26/2024	09/26/2024
Contract Detail	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/15/2015	01/01/2016	04/01/2020	11/24/2020
Contract Detail	AVELLA OF DEER VALLEY, INC. #38	DBA AVELLA SPECIALTY PHARMACY	24416 N. 19TH AVE	PHOENIX	AZ	85085	07/19/2016	10/01/2016	04/14/2021	03/29/2022
Contract Detail	AVELLA OF SACRAMENTO, INC.	2288 AUBURN BLVD #102		SACRAMENTO	CA	95821	04/15/2015	07/01/2015	07/13/2020	03/29/2022
Contract Detail	BARTELL DRUGS #06951	6602- 64TH STREET N.E.		MARYSVILLE	WA	98270	07/11/2016	10/01/2016	03/22/2018	06/27/2018
Contract Detail	BARTELL DRUGS #06964	7205 267TH STREET NW		STANWOOD	WA	98292-6237	01/19/2022	04/01/2022		04/01/2022
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	04/17/2018	07/01/2018	09/12/2019	10/15/2019
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	10/16/2023	01/01/2024	12/11/2024	12/11/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY, INC	3200 LAKE EMMA RD UNIT 1000		LAKE MARY	FL	32746	04/15/2021	07/01/2021	08/08/2024	08/08/2024
Contract Detail	BRIOVARX OF MAINE INC	DBA BRIOVARX	53 DARLING AVE	SOUTH PORTLAND	ME	04106	10/16/2017	01/01/2018	07/24/2019	09/05/2019
Contract Detail	BRIOVARX OF MASSACHUSETTS, LLC	D/B/A BRIOVARX	BLDG 2 - UNIT A 145 BODWELL STREET	AVON	MA	02322	10/16/2017	01/01/2018	07/24/2019	09/05/2019
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	01/13/2020	04/01/2020		04/01/2020
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	01/13/2023	04/01/2023		04/01/2023
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	01/13/2020	04/01/2020		04/01/2020
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	01/13/2023	04/01/2023		04/01/2023
Contract Detail	CENTERWELL PHARMACY, INC.	10737 MARKS WAY		MIRAMAR	FL	33025	07/13/2020	08/04/2020	07/07/2023	10/09/2023
Contract Detail	CENTERWELL PHARMACY, INC.	9843 WINDISCH RD		WEST CHESTER	OH	45069	07/13/2020	08/04/2020	11/22/2024	11/22/2024
Contract Detail	CENTERWELL PHARMACY, INC.	11010 FLORIDA CROWN DRIVE, SUITE 200		ORLANDO	FL	32824	10/09/2023	01/01/2024	05/16/2024	05/24/2024
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	14935 NE 87TH STREET SUITE 101	REDMOND	WA	98052-3474	01/13/2023	04/01/2023	01/17/2025	04/01/2025
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	04/15/2021	07/01/2021		07/01/2021
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	04/15/2021	07/01/2021		07/01/2021
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	01/13/2023	04/01/2023		04/01/2023
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	10/11/2017	01/01/2018	01/03/2023	01/13/2023
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	07/13/2020	08/04/2020	01/24/2022	01/13/2023
Contract Detail	DOGWOOD PHARMACY, INC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER ROAD SUITE K	GREENVILLE	SC	29607-6540	04/17/2018	07/01/2018	09/12/2019	10/15/2019
Contract Detail	DOGWOOD PHARMACY, INC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER ROAD SUITE K	GREENVILLE	SC	29607-6540	10/16/2023	01/01/2024	12/11/2024	12/11/2024
Contract Detail	EVERGREEN PHARMACEUTICAL LLC	OMNICARE OF SEATTLE	12674 GATEWAY DR S	TUKWILA	WA	98168-3307	01/13/2023	04/01/2023	03/26/2025	05/07/2025
Contract Detail	FRED MEYER STORES	ATTN: PHARMACY	920 SOUTH BURLINGTON BLVD	BURLINGTON	WA	98233	03/15/2013	04/01/2013		07/12/2017
Contract Detail	GENOA HEALTHCARE LLC	2722 COLBY AVENUE	STE 328A	EVERETT	WA	98201	01/13/2023	04/01/2023		04/01/2023
Contract Detail	HAGGEN		DBA: HAGGEN FOOD & PHARM. #15 757 HAGGEN DRIVE	BURLINGTON	WA	98233	04/11/2012	04/11/2012	08/03/2016	07/12/2017
Contract Detail	HAGGEN		DBA HAGGEN #55 26603 72ND AVENUE NW	STANWOOD	WA	98292	01/04/2016	04/01/2016	08/03/2016	03/30/2024
Contract Detail	HAGGEN, INC.	HAGGEN FOOD & PHARMACY #69	2601 EAST DIVISION ST	MOUNT VERNON	WA	98274	04/11/2012	04/11/2012	08/03/2016	07/12/2017
Contract Detail	HEALTHY OPTIONS INC	DBA POSTAL PRESCRIPTION SVCS	3500 SE 26TH AVE PO BOX 2718	PORTLAND	OR	97202	10/25/2018	01/01/2019		01/01/2019
Contract Detail	HILLTOP PHARMACY	1223 E DIVISION ST		MOUNT VERNON	WA	98274	06/08/2012	06/08/2012	10/01/2018	10/25/2018
Contract Detail	HILLTOP PHARMACY, LLC	1223 E DIVISION ST		MOUNT VERNON	WA	98274-4101	07/20/2018	10/01/2018	09/04/2024	09/05/2024
Contract Detail	ONCOMED THE ONCOLOGY PHARMACY OF BUFFALO	D/B/A ONCO360	140 JOHN JAMES AUDUBON PKWY STE 101	AMHERST	NY	14228	04/15/2021	07/01/2021		07/01/2021
Contract Detail	OPTION CARE ENTERPRISES, INC.	D/B/A OPTION CARE	728 134TH ST SW BUILDING A, SUITE 128	EVERETT	WA	98204	04/13/2016	07/01/2016		07/12/2017
Contract Detail	OPTION CARE ENTERPRISES, INC.	D/B/A OPTION CARE	11403 BLUEGRASS PARKWAY SUITE 400	LOUISVILLE	KY	40299-2398	04/13/2016	07/01/2016		07/12/2017
Contract Detail	OPTION CARE ENTERPRISES, INC.	D/B/A OPTION CARE	600 BIRCHWOOD AVE SUITE 100	BELLINGHAM	WA	98225-1757	04/12/2016	07/01/2016	09/14/2017	11/14/2017
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	10/16/2017	01/01/2018	10/23/2020	12/03/2020
Contract Detail	OPTUM INFUSION SERVICES 305, LLC	15529 COLLEGE BLVD.		LENEXA	KS	66219-1351	04/15/2021	07/01/2021		07/01/2021
Contract Detail	OPTUM INFUSION SERVICES 404 LLC	2065 NE WILLIAMSON CT	STE B	BEND	OR	97701	04/15/2021	07/01/2021		07/01/2021
Contract Detail	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	04/15/2021	07/01/2021		07/01/2021
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	01/14/2022	01/24/2022		01/25/2022
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	10/16/2017	01/01/2018		10/16/2017
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	10/16/2017	01/01/2018		10/16/2017
Contract Detail	OPTUM PHARMACY 705, LLC	11142 RENNER BLVD		LENEXA	KS	66219	04/15/2021	07/01/2021	05/28/2021	01/13/2023
Contract Detail	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	10/16/2017	01/01/2018	07/24/2019	09/05/2019
Contract Detail	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	07/13/2020	08/04/2020		08/04/2020
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/13/2020	07/13/2020		07/22/2020
Contract Detail	OPTUM PHARMACY 806, INC.	2288 AUBURN BLVD	STE. 102	SACRAMENTO	CA	95821-1618	07/13/2020	07/13/2020	01/10/2023	01/13/2023
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	01/13/2023	04/01/2023		04/01/2023
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	10/11/2017	01/01/2018	10/01/2022	10/17/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2819	1309 NW 23RD AVE.	PORTLAND	OR	97210	04/17/2018	07/01/2018	06/29/2018	07/02/2018
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2926	1001 MADISON ST.	SEATTLE	WA	98104	04/17/2018	07/01/2018	06/29/2018	07/02/2018
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2926	1001 MADISON ST.	SEATTLE	WA	98104	04/17/2018	07/01/2018	06/29/2018	07/02/2018
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2819	1309 NW 23RD AVE.	PORTLAND	OR	97210	07/20/2018	10/01/2018		10/01/2018
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2926	1001 MADISON ST.	SEATTLE	WA	98104	07/20/2018	10/01/2018		10/01/2018
Contract Detail	QFC PHARMACY #879	27008 92ND AVE NW		STANWOOD	WA	98292	03/15/2013	04/01/2013		07/12/2017
Contract Detail	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	04/17/2018	07/01/2018	09/12/2019	10/15/2019
Contract Detail	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	04/17/2018	07/01/2018	09/12/2019	10/15/2019
Contract Detail	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	10/16/2023	01/01/2024	12/11/2024	12/11/2024
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1472	315 EAST COLLEGE WAY	MT VERNON	WA	98273	06/15/2012	06/15/2012		07/12/2017
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1485	1258 STATE AVE	MARYSVILLE	WA	98270	10/23/2014	01/01/2015		07/12/2017
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #0593	911 11TH STREET	ANACORTES	WA	98221	10/23/2014	01/01/2015	03/21/2022	03/29/2022
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1522	20500 OLYMPIC PL NE	ARLINGTON	WA	98223	10/23/2014	01/01/2015	09/02/2018	09/20/2018
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #0534	3532 172ND STREET N.E.	ARLINGTON	WA	98223	10/23/2014	01/01/2015	09/02/2018	09/20/2018
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #0474	1715 BROADWAY	EVERETT	WA	98201	07/13/2016	10/01/2016	04/27/2017	07/12/2017
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #0402	1450 SW ERIE STREET	OAK HARBOR	WA	98277-3104	07/13/2016	10/01/2016	04/27/2017	07/12/2017
Contract Detail	SAFEWAY INC	HAGGEN PHARMACY #3450	2601 E DIVISION ST	MOUNT VERNON	WA	98274	07/19/2016	07/20/2016		07/12/2017
Contract Detail	SAFEWAY INC	HAGGEN PHARMACY #3436	757 HAGGEN DR	BURLINGTON	WA	98233	07/19/2016	07/20/2016		07/12/2017
Contract Detail	SAFEWAY INC	HAGGEN PHARMACY #3480	26603 72ND AVENUE NW	STANWOOD	WA	98292	07/19/2016	07/20/2016		07/12/2017
Contract Detail	SAFEWAY INC	HAGGEN PHARMACY #3493	1815 MAIN ST	FERNDALE	WA	98248	07/20/2018	10/01/2018	03/21/2022	03/29/2022
Contract Detail	SCHAFFNER PHARMACY	339 FERRY ST		SEDRO WOOLLEY	WA	98284	01/10/2019	04/01/2019		04/01/2019
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	04/15/2021	07/01/2021		07/01/2021
Contract Detail	SKAGIT REGIONAL HEALTH PHARMACY	1400 E KINCAID ST		MOUNT VERNON	WA	98274	01/06/2025	04/01/2025		04/01/2025
Contract Detail	SPECIALTY THERAPEUTIC CARE	1311 W SAM HOUSTON PKWY N STE 150		HOUSTON	TX	77043-4015	01/14/2022	04/01/2022	12/04/2023	12/04/2023
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5248	851 MOORE STREET	SEDRO WOOLLEY	WA	98284	10/03/2014	01/01/2015		07/12/2017
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5245	412 EAST COLLEGE WAY	MT VERNON	WA	98273	10/03/2014	01/01/2015		07/12/2017
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5235	17226 SMOKEY POINT BOULEVARD	ARLINGTON	WA	98223	10/03/2014	01/01/2015		07/12/2017
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5250	26817 88TH AVENUE NW	STANWOOD	WA	98292	10/03/2014	01/01/2015		07/12/2017
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5247	31645 STATE ROUTE 20	OAK HARBOR	WA	98277	04/12/2019	07/01/2019		07/01/2019
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5234	1517 COMMERCIAL AVE.	ANACORTES	WA	98221	04/12/2019	07/01/2019		07/01/2019
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/17/2017	04/01/2017		07/12/2017
Contract Detail	WAL-MART PHARMACY 10-2319	1250 S.W. ERIE STREET		OAK HARBOR	WA	98277	10/12/2015	01/01/2016		07/12/2017
Contract Detail	WAL-MART PHARMACY 10-2595	8924 QUILCEDA BLVD.		TULALIP	WA	98271	07/13/2020	08/04/2020	12/01/2023	12/06/2023
Contract Detail	WAL-MART PHARMACY 10-2596	2301 FREEWAY DRIVE		MOUNT VERNON	WA	98273	10/12/2015	01/01/2016		07/12/2017
Contract Detail	WAL-MART PHARMACY 10-3757	4010 172ND STREET		ARLINGTON	WA	98223	10/12/2015	01/01/2016		07/12/2017
Contract Detail	WAL-MART PHARMACY 10-3801	8713 64TH ST. NE		MARYSVILLE	WA	98270	07/14/2020	08/04/2020	12/01/2023	12/06/2023
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/17/2017	04/01/2017		07/12/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15158	404 STATE AVE	MARYSVILLE	WA	98270	10/11/2017	01/01/2018		10/11/2017
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16403	1409 11TH AVE.	SEATTLE	WA	98122	10/11/2017	01/01/2018		10/11/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07131	909 17TH STREET	ANACORTES	WA	98221-2379	10/11/2017	01/01/2018		10/11/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10994	320 HARRISON ST.	SEDRO WOOLLEY	WA	98284-1035	10/11/2017	01/01/2018		10/11/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11300	623 S. BURLINGTON BLVD.	BURLINGTON	WA	98233	10/11/2017	01/01/2018		10/11/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11214	31490 STATE ROUTE 20	OAK HARBOR	WA	98277	10/11/2017	01/01/2018		10/11/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07390	1070 E SUNSET DRIVE	BELLINGHAM	WA	98226-3509	10/11/2017	01/01/2018		10/11/2017
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	10/11/2017	01/01/2018	10/01/2021	11/17/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	10/11/2017	01/01/2018		10/11/2017
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	10/11/2017	01/01/2018		10/11/2017
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	10/11/2017	01/01/2018		10/11/2017
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	01/13/2023	04/01/2023		04/01/2023
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/09/2023	01/01/2024		01/01/2024
Contract Detail	WASHINGTON CVS PHARMACY, L.L.C.	CVS PHARMACY # 17272	16818 TWIN LAKES AVE	MARYSVILLE	WA	98271	01/13/2023	04/01/2023		04/01/2023
Contract Detail	WELLPARTNER, INC	20800 SW 115TH AVE	SUITE 100	TUALATIN	OR	97062	10/22/2014	01/01/2015	07/04/2018	08/01/2018

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH500003A	Child	DSH	SKAGIT VALLEY HOSPITAL	Camano Community Health Clinic	127 N EAST CAMANO DRIVE	CAMANO ISLAND	WA	Active
DSH500003AA	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Mount Vernon -Sleep Medicine	1400 East Kincaid St	Mount Vernon	WA	Terminated
DSH500003AB	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Riverbend -Rheumatology	2320 Freeway Drive	Mount Vernon	WA	Active
DSH500003AC	Child	DSH	SKAGIT VALLEY HOSPITAL	Mount Vernon Surgery Center Podiatry	211 S. 13th St.	Mount Vernon	WA	Active
DSH500003AD	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Mount Vernon-Pulmonary	1400 East Kincaid St	Mount Vernon	WA	Terminated
DSH500003AE	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Mount Vernon-Plastic Surgery	1400 East Kincaid St	Mount Vernon	WA	Active
DSH500003AF	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Cliniic Cascade Skagit Health Alliance-Pediatrics	3823 172nd St NE	Arlington	WA	Terminated
DSH500003AG	Child	DSH	SKAGIT VALLEY HOSPITAL	Mount Vernon Surgery Center Interventional Pain Medicine	211 S. 13th St.	Mount Vernon	WA	Active
DSH500003AH	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Mount Vernon-Optometry	1400 East Kincaid St	Mount Vernon	WA	Terminated
DSH500003AJ	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Sedro Woolley-Optometry	1990 Hospital Dr Suite 200	Sedro Woolley	WA	Terminated
DSH500003AK	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Smokey Point-Occupational Medicine	3823 172nd St NE	Arlington	WA	Terminated
DSH500003AL	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Mount Vernon-Occupational Medicine	1400 East Kincaid St	Mount Vernon	WA	Terminated
DSH500003AM	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Mount Vernon-Neurosurgery	1400 East Kincaid St	Mount Vernon	WA	Terminated
DSH500003AN	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinic Cascade Skagit Health Alliance -Internal Medicine	3823 172nd St Ne	Arlington	WA	Terminated
DSH500003AP	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Sedro Woolley-Internal Medicine	1990 Hospital Drive Suite 200	Sedro Woolley	WA	Terminated
DSH500003AQ	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Stanwood-Internal Medicine	9631 269th St. NW	Stanwood	WA	Terminated
DSH500003AR	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinic Cascade Skagit Health Alliance-Family Medicine	3823 172nd St NE	Arlington	WA	Terminated
DSH500003AS	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clincs Stanwood-Family Medicine	9631 269th St NW	Stanwood	WA	Active
DSH500003AT	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Mount Vernon-Internal Medicine	1400 East Kincaid St	Mount Vernon	WA	Terminated
DSH500003AU	Child	DSH	SKAGIT VALLEY HOSPITAL	Mount Vernon Surgery Center Gastroenterology	211 S. 13th St.	Mount Vernon	WA	Active
DSH500003AV	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Mount Vernon-Family Medicine	1400 East Kincaid St	Mount Vernon	WA	Active
DSH500003AW	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Sedro Woolley Family Medicine	1990 HOSPITAL DR Suite 100	SEDRO WOOLLEY	WA	Terminated
DSH500003AX	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Infectious Disease	1400 East Kincaid	Mount Vernon	WA	Active
DSH500003AY	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Riverbend Endocrinology	2320 Freeway Drive	Mount Vernon	WA	Active
DSH500003AZ	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics - Mount Vernon Nephrology	1400 East Kincaid Street	Mount Vernon	WA	Active
DSH500003B	Child	DSH	SKAGIT VALLEY HOSPITAL	SKAGIT VALLEY KIDNEY CENTER	208 HOSPITAL PARKWAY	MOUNT VERNON	WA	Terminated
DSH500003BA	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics - Benson Medical Group Family Medicine	110 N Laventure Rd, Suite C	Mount Vernon	WA	Terminated
DSH500003BB	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Smokey Point Orthopedics	3823 172nd St NE	Arlington	WA	Active
DSH500003BC	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Smokey Point Dermatology	3823 172nd St NE	Arlington	WA	Active
DSH500003BD	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Smokey Point Family Medicine	3823 172nd St NE	Arlington	WA	Active
DSH500003BE	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Smokey Point Rheumatology	3823 172nd St NE	Arlington	WA	Active
DSH500003BF	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Smokey Point Endocrinology	3823 172nd St NE	Arlington	WA	Active
DSH500003BG	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Smokey Point Podiatry	3823 172nd St NE	Arlington	WA	Active
DSH500003BH	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Smokey Point Neurology	3823 172nd St NE	Arlington	WA	Terminated
DSH500003BJ	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Health - Radiation Therapy	307 S 13th St, Suite 100	Mount Vernon	WA	Active
DSH500003BK	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics - Stanwood Orthopedics	9631 269th St NW	Stanwood	WA	Active
DSH500003BL	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics - Mount Vernon Psychiatry	819 S 13th St	Mount Vernon	WA	Active
DSH500003BM	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics - Stanwood Podiatry	9631 269th St NW	Stanwood	WA	Active
DSH500003BN	Child	DSH	SKAGIT VALLEY HOSPITAL	Mount Vernon Surgery Center - Anesthesia	211 S 13th St	Mount Vernon	WA	Active
DSH500003BP	Child	DSH	SKAGIT VALLEY HOSPITAL	Mount Vernon Surgery Center - Endoscopy	211 S 13th St	Mount Vernon	WA	Active
DSH500003BQ	Child	DSH	SKAGIT VALLEY HOSPITAL	Mount Vernon Surgery Center - ENT	211 S. 13th St.	Mount Vernon	WA	Active
DSH500003BR	Child	DSH	SKAGIT VALLEY HOSPITAL	Mount Vernon Surgery Center - Operating Room	211 S 13th St	Mount Vernon	WA	Active
DSH500003BS	Child	DSH	SKAGIT VALLEY HOSPITAL	Mount Vernon Surgery Center - Post Op	211 S 13th St	Mount Vernon	WA	Active
DSH500003BT	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics - Mount Vernon Midwifery	1400 East Kincaid St	Mount Vernon	WA	Active
DSH500003BU	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics - Station Square Family Medicine	901 S 5th St	Mount Vernon	WA	Active
DSH500003BV	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Health - Pet Scan	307 S 13th St Suite 100	Mount Vernon	WA	Active
DSH500003BW	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Smokey Point Gastroenterology - Gastroenterology	3823 172nd Street NE	Arlington	WA	Approved
DSH500003C	Child	DSH	SKAGIT VALLEY HOSPITAL	Regional Cancer Care Center at Skagit	307 S 13th St, Suite 100	MOUNT VERNON	WA	Active
DSH500003D	Child	DSH	SKAGIT VALLEY HOSPITAL	Regional Cancer Care Center at Smokey Point	3823 172nd St N.E	ARLINGTON	WA	Active
DSH500003H	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinic Cardiology	307 S 13th Street Suite 300	Mount Vernon	WA	Active
DSH500003L	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Residency Family Medicine	819 S 13th St	Mount Vernon	WA	Active
DSH500003M	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Riverbend Dermatology	2320 FREEWAY DRIVE	MOUNT VERNON	WA	Active
DSH500003N	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Riverbend Pediatrics	2320 FREEWAY DR	MOUNT VERNON	WA	Active
DSH500003P	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Riverbend Urgent Care	2320 FREEWAY DR	MOUNT VERNON	WA	Active
DSH500003Q	Child	DSH	SKAGIT VALLEY HOSPITAL	Mount Vernon Surgery Center Orthopedics and Sports Medicine	211 S. 13th St.	MOUNT VERNON	WA	Active
DSH500003R	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Valley Wound Healing Center	208 Hospital Parkway	Mount Vernon	WA	Active
DSH500003S	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Mount Vernon Neurology	1400 East Kincaid St	Mount Vernon	WA	Active
DSH500003T	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Urology	1400 East Kincaid Street	Mount Vernon	WA	Active
DSH500003U	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinic Cascade Skagit Health Alliance-Women's Health	3823 172nd St NE	Arlington	WA	Terminated
DSH500003V	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Mount Vernon -Women's Health	1400 East Kincaid St	Mount Vernon	WA	Active
DSH500003W	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Smokey Point-Urgent Care	3823 172nd St NE	Arlington	WA	Active
DSH500003X	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Station Square -Urgent Care	901 S 5th St	Mount Vernon	WA	Active
DSH500003Y	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Sedro Woolley -Surgery	1990 Hospital Dr Suite 200	Sedro Woolley	WA	Terminated
DSH500003Z	Child	DSH	SKAGIT VALLEY HOSPITAL	Skagit Regional Clinics Mount Vernon -Surgery	1400 East Kincaid St	Mount Vernon	WA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/24/2023 12:31:38 PM	8/21/2024 1:21:54 PM	8/21/2024 1:21 PM
Contacts	Primary Contact	Update	Change Request	Martinez, Alma 340B Program Manager Skagit Valley Hospital. 3608145001	Martinez, Alma K 340B Program Manager Skagit Valley Hospital 3608145001	6/24/2024 1:21 PM
Addresses	Billing Address	Insert	Change Request		Skagit Valley Hospital PO Box 1376 Mount Vernon, WA 98273	3/27/2024 3:07 PM
Contacts	Primary Contact	Update	Profile Change Request	Martinez, Alma 340B Coordinator Skagit Valley Hospital. 3608145001	Martinez, Alma 340B Program Manager Skagit Valley Hospital. 3608145001	3/27/2024 1:27 PM
Details	Last Recertification Date	Update	Recertification	9/8/2022 7:20:49 PM	8/24/2023 12:31:38 PM	8/24/2023 12:31 PM
Contacts	Authorizing Official	Update	AO Change Request	Ishizuka, Paul CFO Skagit Valley Hospital 3608145838	Cesena, Tamara L Chief Financial Officer Public Hospital District No. 1, Skagit County, dba Skagit Regional Health 3604458512	6/1/2023 11:56 AM
Details	Last Recertification Date	Update	Recertification	9/3/2021 9:09:04 AM	9/8/2022 7:20:49 PM	9/8/2022 7:20 PM
Details	Last Recertification Date	Update	Recertification	9/18/2020 10:42:32 AM	9/3/2021 9:09:04 AM	9/3/2021 9:09 AM
Medicaid Billing	NPI: State	Update	Recertification		WA	9/18/2020 10:42 AM
Medicaid Billing	NPI: State	Update	Recertification		WA	9/18/2020 10:42 AM
Medicaid Billing	NPI: State	Update	Recertification		WA	9/18/2020 10:42 AM
Details	Last Recertification Date	Update	Recertification	9/8/2019 10:04:31 AM	9/18/2020 10:42:32 AM	9/18/2020 10:42 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	3990918 (WA)		9/8/2019 10:04 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1093889875 ( )		9/8/2019 10:04 AM
Details	Last Recertification Date	Update	Recertification	8/27/2018 1:42:58 PM	9/8/2019 10:04:31 AM	9/8/2019 10:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/31/2018 10:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3990918	10/31/2018 10:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	10/31/2018 10:47 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1001267 (WA)		10/31/2018 10:47 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2007916 (WA)		10/31/2018 10:47 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	XHSP4716 (CA)		10/31/2018 10:47 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	98722051 (CO)		10/31/2018 10:47 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	275104 (OR)		10/31/2018 10:47 AM
Details	Last Recertification Date	Update	Recertification	11/9/2017 2:58:46 PM	8/27/2018 1:42:58 PM	8/27/2018 1:42 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/1/2018 12:50 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		XHSP4716	6/1/2018 12:50 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	6/1/2018 12:50 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/1/2018 12:50 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		98722051	6/1/2018 12:50 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	6/1/2018 12:50 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/1/2018 12:50 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		275104	6/1/2018 12:50 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	6/1/2018 12:50 PM
Addresses	Shipping Address	Delete	Change Request	Skagit Regional Clinics Mount Vernon Pharmacy 1410 East Kincaid St Mount Vernon, WA 98274		4/18/2018 12:29 PM
Addresses	Shipping Address	Delete	Change Request	Skagit Regional Clinics Sedro Woolley Pharmacy 1990 Hospital Drive, Suite 120 Sedro Woolley, WA 98284		4/18/2018 12:29 PM
Addresses	Shipping Address	Delete	Change Request	Skagit Regional Clinics Riverbend Pharmacy 2320 Freeway Drive Mount Vernon, WA 98273		4/18/2018 12:29 PM
Contacts	Authorizing Official	Update	Change Request	LITAKER, THOMAS CFO 500003 3604458505	Ishizuka, Paul CFO Skagit Valley Hospital 3608145838	1/17/2018 7:41 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	11/9/2017 2:58 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1001267	11/9/2017 2:58 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WA	11/9/2017 2:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	11/9/2017 2:58 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		2007916	11/9/2017 2:58 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WA	11/9/2017 2:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	11/9/2017 2:58 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		7105307	11/9/2017 2:58 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WA	11/9/2017 2:58 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1700969847 ( )		11/9/2017 2:58 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1831131135 ( )		11/9/2017 2:58 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1114340882 ( )		11/9/2017 2:58 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1023332749	11/9/2017 2:58 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1508932427	11/9/2017 2:58 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1053357244	11/9/2017 2:58 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1093889875	11/9/2017 2:58 PM
Details	Last Recertification Date	Update	Recertification	8/24/2016 12:00:00 AM	11/9/2017 2:58:46 PM	11/9/2017 2:58 PM
Contacts	Authorizing Official	Update		LITAKER, THOMAS CFO 3604458505	LITAKER, THOMAS CFO 500003 3604458505	9/28/2017 4:22 PM
Contacts	Primary Contact	Update		Martinez, Alma 340B Coordinator 3608145001	Martinez, Alma 340B Coordinator Skagit Valley Hospital. 3608145001	9/18/2017 4:43 PM
Contacts	Authorizing Official	Insert			LITAKER, THOMAS CFO 3604458505	7/18/2017 6:50 PM
Contacts	Primary Contact	Update		Lai, Cindy Interim Director of Pharmacy 3608142425	Martinez, Alma 340B Coordinator 3608145001	7/12/2017 2:35 PM
Addresses	Main Address	Insert			1415 EAST KINCAID MOUNT VERNON, WA 98274-4126	7/12/2017 2:34 PM
Addresses	Shipping Address	Insert			Skagit Regional Clinics Mount Vernon Pharmacy 1410 East Kincaid St Mount Vernon, WA 98274	7/12/2017 2:34 PM
Addresses	Shipping Address	Insert			Skagit Regional Clinics Sedro Woolley Pharmacy 1990 Hospital Drive, Suite 120 Sedro Woolley, WA 98284	7/12/2017 2:34 PM
Addresses	Shipping Address	Insert			Skagit Regional Clinics Riverbend Pharmacy 2320 Freeway Drive Mount Vernon, WA 98273	7/12/2017 2:34 PM
Medicaid Billing	NPI: Number	Insert			1114340882	8/24/2016 1:44 PM
Details	Last Recertification Date	Update		8/24/2015 12:00:00 AM	8/24/2016 12:00:00 AM	8/24/2016 1:44 PM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/26/2015 2:45 PM
Details	Last Recertification Date	Update		8/21/2014 12:00:00 AM	8/24/2015 12:00:00 AM	8/26/2015 2:45 PM
Details	Last Recertification Date	Update		9/6/2013 12:00:00 AM	8/21/2014 12:00:00 AM	8/21/2014 1:23 PM
Contacts	Primary Contact	Insert			Lai, Cindy Interim Director of Pharmacy 3608142425	7/22/2014 4:50 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/6/2013 12:00:00 AM	9/6/2013 6:45 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/17/2012 9:03 AM
Details	Last Recertification Date	Insert				9/10/2007 11:52 AM
Details	Grant Number	Insert				9/10/2007 11:52 AM
Details	340B ID	Insert			DSH500003	9/10/2007 11:52 AM
Details	Is Authorizing Official EHB Data	Insert				9/10/2007 11:52 AM
Dates	Last Date That 340B Drugs Purchased	Insert				9/10/2007 11:52 AM
Details	Medicare Provider Number	Insert			500003	9/10/2007 11:52 AM
Details	Entity Name	Insert			SKAGIT VALLEY HOSPITAL	9/10/2007 11:52 AM
Details	Program Code	Insert			DSH	9/10/2007 11:52 AM
Details	Entity Subname	Insert				9/10/2007 11:52 AM
Dates	Participating Approval Date	Insert			5/3/2006 12:00:00 AM	9/10/2007 11:52 AM
Details	State	Insert			Active	9/10/2007 11:52 AM
Dates	Registration Date	Insert			5/2/2006 12:00:00 AM	9/10/2007 11:52 AM
Dates	Signed By Date	Insert			4/26/2006 12:00:00 AM	9/10/2007 11:52 AM
Dates	Start Date	Insert			7/1/2006 12:00:00 AM	9/10/2007 11:52 AM
Terminations	Termination Comments	Insert				9/10/2007 11:52 AM
Terminations	Termination Date	Insert				9/10/2007 11:52 AM
Terminations	Termination Effective Date	Insert				9/10/2007 11:52 AM
Terminations	Termination Reason	Insert				9/10/2007 11:52 AM
Details	Comments Public	Insert			9/4/2007- DOC RECD TO CONFIRM ELIG DSH ADJ %	9/10/2007 11:52 AM
Medicaid Billing	Medicaid: Is Primary	Insert			True	5/2/2006 11:29 AM
Medicaid Billing	Medicaid: Number	Insert			3323300	5/2/2006 11:29 AM
Medicaid Billing	Medicaid: State	Insert			WA	5/2/2006 11:29 AM
Medicaid Billing	NPI: Number	Insert			1700969847	5/2/2006 11:29 AM
Medicaid Billing	NPI: Number	Insert			1831131135	5/2/2006 11:29 AM