Covered Entity Details

DSH380007 LEGACY EMANUEL HOSPITAL & HEALTH CENTER (Active) - information as of 5/25/2025 1:12:22 AM

Main Details

Name

LEGACY EMANUEL HOSPITAL & HEALTH CENTER

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH380007

Medicare Provider Number

380007

Additional Details

Current Program Status

Active

Registration Date

6/15/2007

Participating Start Date

7/1/2007

Participating Approval Date

6/15/2007

Last Recertification Date

9/2/2024

Contacts

Authorizing Official

Legacy Health
Kecia Kelly, SVP Chief Nursing Officer
(503) 415-5199

Primary Contact

Legacy Health
Elena Valcarlos, Pharmacy Systems Manager
(503) 413-7764

Addresses

Street Address

2801 N GANTENBEIN AVE
PORTLAND, OR 97227

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
8/16/10 ENTITY NAME CHANGE (WAS LEGACY EMANUEL HOSPITAL AND HEALTH CENTER)	06/15/2007

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	1019958	1831112358
OR	055103,055330	1831112358

Shipping Addresses

Shipping Address 1

Apothecary at Emanuel
501 N Graham St
Portland, OR 97227

Shipping Address 2

Unity Center for Behavioral Health
1225 NE 2nd Ave
Portland, OR 97232

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	07/15/2020	10/01/2020		10/01/2020
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/15/2020	10/01/2020		10/01/2020
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	07/15/2020	10/01/2020		10/01/2020
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	07/15/2020	10/01/2020		10/01/2020
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/15/2020	10/01/2020		10/01/2020
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	07/15/2020	10/01/2020		10/01/2020
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	10/12/2017	01/01/2018		10/12/2017
Contract Detail	APOTHECARY AT GOOD SAMARITAN	1040 NW 22ND AVE	STE 100	PORTLAND	OR	97210	01/14/2022	04/01/2022		04/01/2022
Contract Detail	APOTHECARY AT SALMON CREEK	2121 NE 139TH ST STE 310		VANCOUVER	WA	98686	01/14/2019	04/01/2019		01/10/2020
Contract Detail	ARDON HEALTH, LLC	11835 NE GLENN WIDING DR		PORTLAND	OR	97220-9057	10/12/2020	01/01/2021		01/01/2021
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	10/03/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	10/12/2017	01/01/2018		10/12/2017
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	10/03/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	10/03/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	10/03/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	10/03/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	10/03/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	10/03/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	10/12/2017	01/01/2018		10/12/2017
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	10/03/2021	01/01/2022		01/01/2022
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	7358 S W DURHAM ROAD	PORTLAND	OR	97224	10/12/2017	01/01/2018	01/24/2025	04/16/2025
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	10/03/2021	01/01/2022		01/01/2022
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	10/03/2021	01/01/2022		01/01/2022
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	10/03/2021	01/01/2022		01/01/2022
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/10/2020	07/01/2020		07/01/2020
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	07/15/2020	10/01/2020		10/01/2020
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	07/15/2020	10/01/2020		10/01/2020
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	07/15/2020	10/01/2020		10/01/2020
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	07/15/2020	10/01/2020		10/01/2020
Contract Detail	FRED MEYER	3805 SE HAWTHORNE BLVD		PORTLAND	OR	97214	07/26/2012	07/26/2012	02/25/2018	02/25/2018
Contract Detail	FRED MEYER	7404 N. INTERSTATE AVE		PORTLAND	OR	97217	07/26/2012	07/26/2012	02/25/2018	02/25/2018
Contract Detail	FRED MEYER	1111 NE 102ND AVENUE		PORTLAND	OR	97220	04/10/2020	07/01/2020		07/01/2020
Contract Detail	FRED MEYER	7404 N. INTERSTATE AVE		PORTLAND	OR	97217	04/10/2020	07/01/2020		07/01/2020
Contract Detail	FRED MEYER	6615 NE GLISAN ST		PORTLAND	OR	97213	04/10/2020	07/01/2020		07/01/2020
Contract Detail	FRED MEYER INC	ATTN: PHARMACY	3030 NE WEIDLER	PORTLAND	OR	97232	07/26/2012	07/26/2012	02/25/2018	02/25/2018
Contract Detail	FRED MEYER INC	6850 N LOMBARD		PORTLAND	OR	97203	04/10/2020	07/01/2020		07/01/2020
Contract Detail	FRED MEYER INC	ATTN: PHARMACY	3030 NE WEIDLER	PORTLAND	OR	97232	04/10/2020	07/01/2020		07/01/2020
Contract Detail	FRED MEYER STORES INC	FRED MEYER PHARMACY #360	100 NW 20TH PLACE	PORTLAND	OR	97209	07/26/2012	07/26/2012	02/25/2018	02/25/2018
Contract Detail	FRED MEYER STORES INC	FRED MEYER PHARMACY #360	100 NW 20TH PLACE	PORTLAND	OR	97209	04/10/2020	07/01/2020		07/01/2020
Contract Detail	FRED MEYER STORES INC	FRED MEYER PHARMACY #462	51501 COLUMBIA RIVER HWY	SCAPPOOSE	OR	97056	04/10/2020	07/01/2020		07/01/2020
Contract Detail	HEALTHY OPTIONS INC	DBA POSTAL PRESCRIPTION SVCS	3500 SE 26TH AVE PO BOX 2718	PORTLAND	OR	97202	01/12/2016	04/01/2016	02/25/2018	02/25/2018
Contract Detail	HEALTHY OPTIONS INC	DBA POSTAL PRESCRIPTION SVCS	3500 SE 26TH AVE PO BOX 2718	PORTLAND	OR	97202	04/10/2020	07/01/2020		07/01/2020
Contract Detail	LEGACY MT. HOOD MEDICAL CENTER PHARMACY	24800 SE STARK ST		GRESHAM	OR	97030-3378	01/14/2022	04/01/2022		04/01/2022
Contract Detail	OPTION CARE ENTERPRISES, INC.	D/B/A OPTION CARE	11403 BLUEGRASS PARKWAY SUITE 400	LOUISVILLE	KY	40299-2398	01/05/2017	04/01/2017		01/05/2017
Contract Detail	OPTION CARE LEGACY HEALTH, LLC	D/B/A OPTION CARE AT LEGACY HEALTH	16195 S.W. 72ND AVENUE	PORTLAND	OR	97224-7766	01/05/2017	04/01/2017		01/05/2017
Contract Detail	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	01/10/2021	04/01/2021		04/01/2021
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	10/12/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	10/12/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	10/12/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 705, LLC	11142 RENNER BLVD		LENEXA	KS	66219	10/12/2020	01/01/2021	04/15/2024	04/15/2024
Contract Detail	OPTUM PHARMACY 705, LLC	1893 GENERAL GEORGE PATTON DR	STE 106	FRANKLIN	TN	37067-2655	10/12/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	04/15/2024	07/01/2024		07/01/2024
Contract Detail	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	10/12/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	10/12/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 806, INC.	2288 AUBURN BLVD	STE. 102	SACRAMENTO	CA	95821-1618	10/12/2020	01/01/2021	04/15/2024	04/15/2024
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	04/15/2024	07/01/2024		07/01/2024
Contract Detail	OREGON CVS PHARMACY, L.L.C.	CVS PHARMACY # 17632	1555 N TOMAHAWK ISLAND DR	PORTLAND	OR	97217	04/10/2020	07/01/2020		07/01/2020
Contract Detail	OREGON CVS PHARMACY, L.L.C.	CVS PHARMACY # 16125	10775 SW BEAVERTON HILLSDALE HWY	BEAVERTON	OR	97005	04/10/2020	07/01/2020		07/01/2020
Contract Detail	OREGON CVS PHARMACY, L.L.C.	CVS PHARMACY # 16757	9800 SE WASHINGTON ST	PORTLAND	OR	97216	04/10/2020	07/01/2020		07/01/2020
Contract Detail	OREGON CVS PHARMACY, L.L.C.	CVS PHARMACY # 16336	18101 NW EVERGREEN PKWY	BEAVERTON	OR	97006	04/10/2020	07/01/2020		07/01/2020
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	04/10/2020	07/01/2020	10/01/2022	10/07/2022
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	10/12/2017	01/01/2018		10/12/2017
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2819	1309 NW 23RD AVE.	PORTLAND	OR	97210	10/12/2017	01/01/2018		10/12/2017
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #11280	538 SW 4TH AVENUE	PORTLAND	OR	97204	04/10/2020	07/01/2020	09/17/2021	10/03/2021
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	10/03/2021	01/01/2022		01/01/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	10/03/2021	01/01/2022		01/01/2022
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #2448	1010 SW JEFFERSON ST	PORTLAND	OR	97201-3425	04/04/2012	04/04/2012	10/16/2016	03/01/2017
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #2790	1303 NW LOVEJOY ST	PORTLAND	OR	97209	04/04/2012	04/04/2012	10/16/2016	03/01/2017
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1612	1100 NE BROADWAY ST	PORTLAND	OR	97232	04/04/2012	04/04/2012	10/16/2016	03/01/2017
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #0509	5920 NE MLK BLVD	PORTLAND	OR	97211	04/04/2012	04/04/2012	10/16/2016	03/01/2017
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1447	6901 NE SANDY BLVD	PORTLAND	OR	97213	05/03/2023	07/01/2023	08/17/2024	10/28/2024
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1612	1100 NE BROADWAY ST	PORTLAND	OR	97232	05/03/2023	07/01/2023	08/17/2024	10/28/2024
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #0509	5920 NE MLK BLVD	PORTLAND	OR	97211	05/03/2023	07/01/2023	08/17/2024	10/28/2024
Contract Detail	SILVERTON HEALTH	WOODBURN HEALTH CENTER PHARMACY	1475 MOUNT HOOD AVE STE 100	WOODBURN	OR	97071	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #16251	7070 NE SANDY BLVD	PORTLAND	OR	97213	04/10/2020	07/01/2020	11/16/2021	01/13/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07119	5420 NE 33RD AVE	PORTLAND	OR	97211-7404	04/10/2020	07/01/2020	11/17/2021	11/29/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09544	10903 SE OAK ST	MILWAUKIE	OR	97222-6641	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 15927	11995 SE SUNNYSIDE RD	HAPPY VALLEY	OR	97015	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03890	940 SE CESAR E CHAVEZ BLVD	PORTLAND	OR	97214	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05952	7280 SW BEAVERTON-HILLSDALE HWY	PORTLAND	OR	97225	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03925	3 NE 82ND AVE	PORTLAND	OR	97220	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10056	175 S. COLUMBIA RIVER HWY.	SAINT HELENS	OR	97051	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03817	4285 W POWELL BLVD	GRESHAM	OR	97030	04/10/2020	07/01/2020	10/10/2023	10/30/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09625	17850 LOWER BOONES FERRY RD	LAKE OSWEGO	OR	97035	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05780	13939 SW PACIFIC HWY	TIGARD	OR	97223	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06426	12335 NE GLISAN ST	PORTLAND	OR	97230	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10137	38241 PROCTOR BLVD.	SANDY	OR	97055-8019	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06140	1620 NE GRAND AVE	PORTLAND	OR	97232	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06831	7010 NE CORNELL ROAD	HILLSBORO	OR	97124-5422	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06370	14600 SW MURRAY SCHOLLS DR #201	BEAVERTON	OR	97007	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05910	25699 SE STARK ST	TROUTDALE	OR	97060	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21151	1215 NW 23RD AVE	PORTLAND	OR	97210	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04495	2103 W. BURNSIDE	PORTLAND	OR	97210	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04353	4325 82ND SE	PORTLAND	OR	97266	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11398	439 NE 223RD AVE.	GRESHAM	OR	97030	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05647	6116 NE MLK JR BLVD	PORTLAND	OR	97211	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04296	3909 SE HOLGATE BLVD	PORTLAND	OR	97202	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07688	9450 SW WILSONVILLE RD	WILSONVILLE	OR	97070	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05572	2829 N LOMBARD ST	PORTLAND	OR	97217	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01100	9159 SE 82ND AVE	HAPPY VALLEY	OR	97086	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15071	13470 NW CORNELL RD	PORTLAND	OR	97229-5651	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01082	4816 NW BETHANY BLVD	PORTLAND	OR	97229-9254	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04943	12215 SE POWELL BLVD.	PORTLAND	OR	97236	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03801	1310 MOLALLA AVE	OREGON CITY	OR	97045	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03838	1950 NE BURNSIDE RD	GRESHAM	OR	97030	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15154	9855 SW CAPITOL HWY.	PORTLAND	OR	97219	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05816	9812 NE HIGHWAY 99	VANCOUVER	WA	98665	10/03/2021	01/01/2022		01/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07119	5420 NE 33RD AVE	PORTLAND	OR	97211-7404	01/12/2024	04/01/2024		04/01/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	04/10/2020	07/01/2020	10/01/2021	11/22/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/10/2020	07/01/2020		07/01/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/10/2020	07/01/2020		07/01/2020

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH380007B	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Legacy Emanuel Magnetic Resonance Imaging / MRI 150-3523	501 N Graham St	Portland	OR	Active
DSH380007C	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Legacy Emanuel Rehabilitation / OP Rehab 150-3669	300 N Graham St	Portland	OR	Active
DSH380007D	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Legacy Emanuel Medication Management Services / Legacy Medication Mgmt Service 150-3719	501 N Graham St	Portland	OR	Active
DSH380007E	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Legacy Emanuel Wound Care Center / Chronic Wound Care Center 150-2165	3001 N Gantenbein Ave	Portland	OR	Active
DSH380007F	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Legacy Emanuel Day Treatment Unit / Day Treatment Clinics 150-3552	501 N Graham St	Portland	OR	Active
DSH380007G	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Legacy Medical Group Internal Medicine Emanuel / LMG Emanuel IM 155-3906	2800 N Vancouver Ave	Portland	OR	Active
DSH380007H	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Legacy Medical Group Broadway / LMG Broadway 155-8360	1600 NE BROADWAY ST	PORTLAND	OR	Active
DSH380007J	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Legacy Medical Group Northeast / LMG Northeast 155-8030	300 N Graham St	Portland	OR	Active
DSH380007K	Child	DSH	LEGACY EMANUEL MEDICAL CENTER	LEMC Podiatry	2800 N Vancouver Ste 130	Portland	OR	Terminated
DSH380007L	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Legacy Medical Group Gynecology Emanuel / LMG Emanuel IM Gynecology 155-3906	2800 N Vancouver Ave	Portland	OR	Active
DSH380007M	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Legacy Emanuel Occupational Therapy - Wound Care Center / OP Rehab 150-3669	3001 N Gantenbein Ave	Portland	OR	Active
DSH380007N	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Unity Center for Behavioral Health Emergency Department - A Service of Legacy Emanuel - Unity Center for Behavioral Health Emergency Department	1225 NE 2ND AVE	PORTLAND	OR	Terminated
DSH380007P	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Legacy Emanuel Bone Clinic / Chronic Wound Care Center 150-2165	3001 N Gantenbein Ave	Portland	OR	Active
DSH380007Q	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Legacy Emanuel Devers Eye Institute / Devers Eye Clinic 150-3903	300 N Graham St	Portland	OR	Active
DSH380007R	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Legacy Emanuel Hyperbaric Program / Hyperbaric Medicine 150-2168	3001 N Gantenbein Ave	Portland	OR	Active
DSH380007S	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Legacy Emanuel Cardiopulmonary / Respiratory Therapy 150-3110	501 N Graham St	Portland	OR	Active
DSH380007T	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Legacy Emanuel Trauma NeuroTrauma Clinic - Trauma Clinic 150-2269	300 N Graham St	Portland	OR	Terminated
DSH380007U	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Legacy Emanuel Cardiac Rehabilitation / Cardiac Rehab 150-3440	501 N Graham St	Portland	OR	Active
DSH380007V	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Legacy Emanuel Infusion Services IV Clinic / IV Therapy 150-3716	501 N Graham St	Portland	OR	Active
DSH380007W	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	Legacy Emanuel Radiation Oncology / Radiology Diagnostic 150-3512	450 N Graham St	Portland	OR	Terminated
DSH380007X	Child	DSH	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	UBH PES Center for Behavioral Health Emergency Department - Psychiatric Emergency Services 170-3280	1225 NE 2nd Ave	Portland	OR	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Tanas, Majid VP Pharmacy Services Legacy Health 5034155011	Kelly, Kecia SVP Chief Nursing Officer Legacy Health 5034155199	9/12/2024 11:17 AM
Details	Last Recertification Date	Update	Recertification	9/8/2023 8:59:42 AM	9/2/2024 10:42:40 AM	9/2/2024 10:42 AM
Addresses	Shipping Address	Insert	Change Request		Unity Center for Behavioral Health 1225 NE 2nd Ave Portland, OR 97232	1/24/2024 9:29 AM
Addresses	Shipping Address	Insert	Recertification		Apothecary at Emanuel 501 N Graham St Portland, OR 97227	9/8/2023 8:59 AM
Addresses	Main Address	Update	Recertification	2801 N. GANTENBEIN PORTLAND, OR 97227	2801 N GANTENBEIN AVE PORTLAND, OR 97227	9/8/2023 8:59 AM
Addresses	Shipping Address	Delete	Recertification	Apothecary at Emanuel 501 N. Graham Portland, OR 97227		9/8/2023 8:59 AM
Details	Last Recertification Date	Update	Recertification	9/8/2022 2:16:40 PM	9/8/2023 8:59:42 AM	9/8/2023 8:59 AM
Details	Last Recertification Date	Update	Recertification	9/13/2021 11:47:58 AM	9/8/2022 2:16:40 PM	9/8/2022 2:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/13/2022 6:55 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1019958	6/13/2022 6:55 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	6/13/2022 6:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/13/2022 6:55 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		055103	6/13/2022 6:55 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	6/13/2022 6:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/13/2022 6:55 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		055330	6/13/2022 6:55 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	6/13/2022 6:55 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1831112358	6/13/2022 6:55 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	6/13/2022 6:55 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1831112358	6/13/2022 6:55 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	6/13/2022 6:55 PM
Details	Last Recertification Date	Update	Recertification	9/8/2020 9:28:15 AM	9/13/2021 11:47:58 AM	9/13/2021 11:47 AM
Contacts	Authorizing Official	Update	Change Request	Loomis, Anna SVP Chief Financial Officer Legacy Health 5034155730	Tanas, Majid VP Pharmacy Services Legacy Health 5034155011	1/11/2021 8:00 AM
Details	Last Recertification Date	Update	Recertification	9/9/2019 7:44:38 AM	9/8/2020 9:28:15 AM	9/8/2020 9:28 AM
Contacts	Primary Contact	Update	Profile Change Request	Valcarlos, Elena Pharmacy Operations Manager Legacy Health 5034137764	Valcarlos, Elena Pharmacy Systems Manager Legacy Health 5034137764	1/31/2020 4:08 PM
Contacts	Primary Contact	Update	Profile Change Request	Valcarlos, Elena Pharmacy Operations Manager Legacy Health 5034131321	Valcarlos, Elena Pharmacy Operations Manager Legacy Health 5034137764	1/31/2020 4:08 PM
Contacts	Authorizing Official	Update	Change Request	Bradley, Carol SVP and Chief Nursing Officer Legacy Health 5034155199	Loomis, Anna SVP Chief Financial Officer Legacy Health 5034155730	9/16/2019 5:17 AM
Details	Last Recertification Date	Update	Recertification	8/20/2018 8:15:39 PM	9/9/2019 7:44:38 AM	9/9/2019 7:44 AM
Contacts	Primary Contact	Update	Change Request	Agee, Jennifer Director, Supply Chain Legacy Health 5039444202	Valcarlos, Elena Pharmacy Operations Manager Legacy Health 5034131321	8/8/2019 7:26 AM
Contacts	Primary Contact	Update	Change Request	Stoner, Kathleen C. Vice President Supply Chain and Pharmacy Services Legacy Health 5039444276	Agee, Jennifer Director, Supply Chain Legacy Health 5039444202	3/1/2019 3:23 PM
Contacts	Authorizing Official	Update	Change Request	Newcomb III, Everett W. Sr Vice President and COO Legacy Health 5034155252	Bradley, Carol SVP and Chief Nursing Officer Legacy Health 5034155199	12/19/2018 12:49 PM
Contacts	Primary Contact	Update	Profile Change Request	Stoner, Kathleen C. Director, LH Pharmacy Services Legacy Health 5034136926	Stoner, Kathleen C. Vice President Supply Chain and Pharmacy Services Legacy Health 5039444276	9/7/2018 1:25 PM
Details	Last Recertification Date	Update	Recertification	11/29/2017 8:38:01 PM	8/20/2018 8:15:39 PM	8/20/2018 8:15 PM
Details	Last Recertification Date	Update	Recertification	8/31/2016 12:00:00 AM	11/29/2017 8:38:01 PM	11/29/2017 8:38 PM
Contacts	Authorizing Official	Update		Newcomb III, Everett W. Sr Vice President and COO 5034155252	Newcomb III, Everett W. Sr Vice President and COO Legacy Health 5034155252	10/11/2017 1:31 PM
Contacts	Primary Contact	Update		Stoner, Kathleen C. Director, LH Pharmacy Services 5034136926	Stoner, Kathleen C. Director, LH Pharmacy Services Legacy Health 5034136926	10/11/2017 12:40 PM
Contacts	Primary Contact	Insert			Stoner, Kathleen C. Director, LH Pharmacy Services 5034136926	6/12/2017 2:32 PM
Contacts	Authorizing Official	Update		VUKOVICH, PAMELA S. SR. VP & CFO 5034155730	Newcomb III, Everett W. Sr Vice President and COO 5034155252	6/12/2017 2:32 PM
Addresses	Main Address	Insert			2801 N. GANTENBEIN PORTLAND, OR 97227	11/15/2016 12:35 PM
Addresses	Shipping Address	Insert			Apothecary at Emanuel 501 N. Graham Portland, OR 97227	11/15/2016 12:35 PM
Details	Entity Name	Update		LEGACY EMANUEL MEDICAL CENTER	LEGACY EMANUEL HOSPITAL & HEALTH CENTER	11/15/2016 12:35 PM
Details	Last Recertification Date	Update		9/1/2015 12:00:00 AM	8/31/2016 12:00:00 AM	8/31/2016 6:01 PM
Details	Last Recertification Date	Update		8/27/2014 12:00:00 AM	9/1/2015 12:00:00 AM	9/1/2015 6:13 PM
Details	Last Recertification Date	Update		9/9/2013 12:00:00 AM	8/27/2014 12:00:00 AM	8/27/2014 11:24 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/9/2013 12:00:00 AM	9/9/2013 9:32 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/21/2012 7:28 AM
Contacts	Authorizing Official	Insert			VUKOVICH, PAMELA S. SR. VP & CFO 5034155730	2/17/2011 1:54 PM
Details	Last Recertification Date	Insert				6/15/2007 3:23 PM
Details	Grant Number	Insert				6/15/2007 3:23 PM
Details	340B ID	Insert			DSH380007	6/15/2007 3:23 PM
Details	Is Authorizing Official EHB Data	Insert				6/15/2007 3:23 PM
Dates	Last Date That 340B Drugs Purchased	Insert				6/15/2007 3:23 PM
Details	Medicare Provider Number	Insert			380007	6/15/2007 3:23 PM
Details	Entity Name	Insert			LEGACY EMANUEL MEDICAL CENTER	6/15/2007 3:23 PM
Details	Program Code	Insert			DSH	6/15/2007 3:23 PM
Details	Entity Subname	Insert				6/15/2007 3:23 PM
Dates	Participating Approval Date	Insert			6/15/2007 12:00:00 AM	6/15/2007 3:23 PM
Details	State	Insert			Active	6/15/2007 3:23 PM
Dates	Registration Date	Insert			6/15/2007 12:00:00 AM	6/15/2007 3:23 PM
Dates	Signed By Date	Insert			5/30/2007 12:00:00 AM	6/15/2007 3:23 PM
Dates	Start Date	Insert			7/1/2007 12:00:00 AM	6/15/2007 3:23 PM
Terminations	Termination Comments	Insert				6/15/2007 3:23 PM
Terminations	Termination Date	Insert				6/15/2007 3:23 PM
Terminations	Termination Effective Date	Insert				6/15/2007 3:23 PM
Terminations	Termination Reason	Insert				6/15/2007 3:23 PM
Details	Comments Public	Insert			8/16/10 ENTITY NAME CHANGE (WAS LEGACY EMANUEL HOSPITAL AND HEALTH CENTER)	6/15/2007 3:23 PM