Covered Entity Details

DSH380061 PROVIDENCE PORTLAND MEDICAL CENTER (Active) - information as of 5/27/2025 11:43:39 PM

Main Details

Name

PROVIDENCE PORTLAND MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH380061

Medicare Provider Number

380061

Additional Details

Current Program Status

Active

Registration Date

4/8/2015

Participating Start Date

7/1/2015

Participating Approval Date

5/20/2015

Last Recertification Date

9/4/2024

Contacts

Authorizing Official

Providence
Kate Buzbee, CFO
(971) 300-4268

Primary Contact

Providence Health and Services
Mac Ovenell, 340B Director
(509) 860-8643

Addresses

Street Address

4805 NE GLISAN ST
PORTLAND, OR 97213

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

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
OR	150300	1003991845
WA	1000242	1003991845
CA		1003991845
AK		1003991845
ID		1003991845

Shipping Addresses

Shipping Address 1

Safecor Health
4060 Business Park Drive
Columbus, OH 43204

Shipping Address 2

PROVIDENCE PORTLAND MEDICAL CENTER
4805 NE GLISAN ST
PORTLAND, OR 97213

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	07/14/2017	10/01/2017		10/01/2017
Contract Detail	ACCREDO HEALTH GROUP INC	201 GREAT CIRCLE ROAD		NASHVILLE	TN	37228	07/14/2017	10/01/2017	01/05/2018	01/09/2018
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/14/2017	10/01/2017		10/01/2017
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	07/14/2017	10/01/2017		10/01/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	07/14/2017	10/01/2017		10/01/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	07/14/2017	10/01/2017		10/01/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/14/2017	10/01/2017		10/01/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	01/17/2022	04/01/2022		04/01/2022
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	07/15/2020	10/01/2020		10/01/2020
Contract Detail	AETNA SPECIALTY PHARMACY, LLC	503 SUNPORT LN		ORLANDO	FL	32809-7874	04/14/2019	07/01/2019		07/01/2019
Contract Detail	ALBERTSONS LLC	SAV-ON PHARMACY #3531	16199 BOONES FERRY RD	LAKE OSWEGO	OR	97035	04/03/2019	07/01/2019		07/01/2019
Contract Detail	ARDON HEALTH, LLC	11835 NE GLENN WIDING DR		PORTLAND	OR	97220-9057	07/12/2019	10/01/2019		10/01/2019
Contract Detail	BIOPLUS SPECIALTY INFUSION CA, LLC	19110 VAN NESS AVE.		TORRANCE	CA	90501	07/12/2019	10/01/2019		10/01/2019
Contract Detail	BIOPLUS SPECIALTY PHARMACY CA	7373 LINCOLN WAY		GARDEN GROVE	CA	92841	07/12/2019	10/01/2019		10/01/2019
Contract Detail	BIOPLUS SPECIALTY PHARMACY LA, LLC	2731 MANHATTAN BLVD STE B17		HARVEY	LA	70058	07/12/2019	10/01/2019		10/01/2019
Contract Detail	BIOPLUS SPECIALTY PHARMACY, INC	3200 LAKE EMMA RD UNIT 1000		LAKE MARY	FL	32746	07/12/2019	10/01/2019		10/01/2019
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/14/2017	07/01/2017		04/20/2017
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/14/2017	07/01/2017		04/20/2017
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/14/2017	07/01/2017		04/20/2017
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/14/2017	07/01/2017		04/20/2017
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/14/2017	07/01/2017		04/20/2017
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/14/2017	07/01/2017		04/20/2017
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/14/2017	07/01/2017		04/20/2017
Contract Detail	CAREMARK PUERTO RICO SPECIALTY PHARMACY,	CAREMARK PUERTO RICO SPECIALTY PHARMACY	6020 AVE ROBERTO SANCHEZ VILELLA	CAROLINA	PR	00982	07/15/2020	10/01/2020		10/01/2020
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/14/2017	07/01/2017		04/20/2017
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/14/2017	07/01/2017		04/20/2017
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/15/2020	10/01/2020		10/01/2020
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	7358 S W DURHAM ROAD	PORTLAND	OR	97224	04/14/2017	07/01/2017		04/20/2017
Contract Detail	CREDENA HEALTH LLC	7376 SW DURHAM RD		PORTLAND	OR	97224	10/14/2022	01/01/2023		01/01/2023
Contract Detail	CREDENA HEALTH PHARMACY PPMC PLAZA	5050 NE HOYT ST STE 142		PORTLAND	OR	97213	04/14/2019	07/01/2019		07/01/2019
Contract Detail	CREDENA HEALTH PHARMACY ST VINCENT	9155 SW BARNES RD STE 102		PORTLAND	OR	97225-6625	04/14/2019	07/01/2019		07/01/2019
Contract Detail	CREDENA HEALTH, LLC	6348 NE HALSEY ST	SUITE A	PORTLAND	OR	97213-4720	07/27/2016	10/01/2016		04/20/2017
Contract Detail	CREDENA HEALTH, LLC	DBA: CREDENA HEALTH PHARMACY FRANZ	4805 NE GLISAN ST STE 11N321	PORTLAND	OR	97213	10/04/2018	01/01/2019		01/01/2019
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/15/2020	10/01/2020		10/01/2020
Contract Detail	CYSTIC FIBROSIS SERVICES	CYSTIC FIBROSIS SERVICES, INC	10530 JOHN W ELLIOTT DR, STE 200	FRISCO	TX	75033	01/17/2017	04/01/2017	09/25/2017	09/26/2017
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/03/2017	07/01/2017		07/03/2017
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	01/14/2017	04/01/2017		04/20/2017
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	G3320 BEECHER RD		FLINT	MI	48532-3614	07/12/2019	10/01/2019		10/01/2019
Contract Detail	DIPLOMAT SPECIALTY PHARMACY OF PHOENIX,	DIPLOMAT SPECIALTY PHARMACY	485 N. JUNIPER DR	CHANDLER	AZ	85226	07/12/2019	10/01/2019		10/01/2019
Contract Detail	DIPLOMAT SPECIALTY PHARMACY OF SOUTHERN	DIPLOMAT SPECIALTY PHARMACY	1809 EXCISE AVENUE SUITE 204-208	ONTARIO	CA	91761	01/14/2017	04/01/2017	07/11/2019	07/12/2019
Contract Detail	FRED MEYER	1111 NE 102ND AVENUE		PORTLAND	OR	97220	07/12/2019	10/01/2019		10/01/2019
Contract Detail	FRED MEYER	3805 SE HAWTHORNE BLVD		PORTLAND	OR	97214	07/12/2019	10/01/2019		10/01/2019
Contract Detail	FRED MEYER	2497 SE BURNSIDE RD		GRESHAM	OR	97080	07/12/2019	10/01/2019		10/01/2019
Contract Detail	FRED MEYER	6615 NE GLISAN ST		PORTLAND	OR	97213	07/15/2020	10/01/2020		10/01/2020
Contract Detail	FRED MEYER	7404 N. INTERSTATE AVE		PORTLAND	OR	97217	07/15/2020	10/01/2020		10/01/2020
Contract Detail	FRED MEYER	7700 S.W. BEAVERTON-HILLSDALE		PORTLAND	OR	97225	07/15/2020	10/01/2020		10/01/2020
Contract Detail	FRED MEYER	CLACKAMAS STORE	16301 S E 82ND DRIVE	CLACKAMAS	OR	97015	07/15/2020	10/01/2020		10/01/2020
Contract Detail	FRED MEYER #040	7555 SW BARBUR BLVD		PORTLAND	OR	97219	07/15/2020	10/01/2020		10/01/2020
Contract Detail	FRED MEYER #660	PHARMACY DEPARTMENT	22855 NE PARKLANE	WOOD VILLAGE	OR	97060	07/12/2019	10/01/2019		10/01/2019
Contract Detail	FRED MEYER 663	16625 362ND AVENUE		SANDY	OR	97055	07/15/2020	10/01/2020		10/01/2020
Contract Detail	FRED MEYER INC	8955 S.E. 82ND AVENUE		HAPPY VALLEY	OR	97086	07/12/2019	10/01/2019		10/01/2019
Contract Detail	FRED MEYER INC	ATTN: PHARMACY	3030 NE WEIDLER	PORTLAND	OR	97232	07/12/2019	10/01/2019		10/01/2019
Contract Detail	FRED MEYER INC	6850 N LOMBARD		PORTLAND	OR	97203	07/15/2020	10/01/2020		10/01/2020
Contract Detail	FRED MEYER INC	DBA FRED MEYER	15995 S.W. WALKER ROAD	BEAVERTON	OR	97006-4944	07/15/2020	10/01/2020		10/01/2020
Contract Detail	FRED MEYER INC	PHARMACY DEPARTMENT	14700 SE DIVISION	PORTLAND	OR	97236	07/15/2020	10/01/2020		10/01/2020
Contract Detail	FRED MEYER PHARMACY #694	17005 SE SUNNYSIDE RD		CLACKAMAS	OR	97015	07/15/2020	10/01/2020		10/01/2020
Contract Detail	FRED MEYER STORES INC	FRED MEYER PHARMACY #360	100 NW 20TH PLACE	PORTLAND	OR	97209	07/15/2020	10/01/2020		10/01/2020
Contract Detail	FRED MEYER STORES INC	FRED MEYER PHARMACY #240	14700 SE MCLOUGHLIN BLVD	MILWAUKIE	OR	97267-1417	07/15/2020	10/01/2020		10/01/2020
Contract Detail	FRED MEYER STORES INC	FRED MEYER PHARMACY #242	1839 MOLALLA AVENUE	OREGON CITY	OR	97045	07/15/2020	10/01/2020		10/01/2020
Contract Detail	HEALTHY OPTIONS INC	DBA POSTAL PRESCRIPTION SVCS	3500 SE 26TH AVE PO BOX 2718	PORTLAND	OR	97202	07/12/2019	10/01/2019		10/01/2019
Contract Detail	KROGER SPECIALTY PHARMACY FL 2	6435 HAZELTINE NATIONAL DR STE 140		ORLANDO	FL	32822-5156	07/12/2019	10/01/2019		10/01/2019
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	04/17/2017	07/01/2017		04/20/2017
Contract Detail	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	10/16/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	01/17/2022	01/24/2022		01/25/2022
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/17/2017	07/01/2017		04/20/2017
Contract Detail	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	10/16/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	04/17/2017	07/01/2017		04/20/2017
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	10/16/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	10/16/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	10/16/2020	01/01/2021		01/01/2021
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	10/02/2017	01/01/2018		10/02/2017
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/14/2017	07/01/2017		04/20/2017
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/15/2020	10/01/2020		10/01/2020
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/15/2020	10/01/2020		10/01/2020
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	10/16/2020	01/01/2021		01/01/2021
Contract Detail	PROVIDENCE HEALTH & SERVICES - OREGON	PROVIDENCE PLAZA PHARMACY	5050 NE HOYT STREET SUITE #142	PORTLAND	OR	97213	07/13/2015	10/01/2015	04/01/2019	04/15/2020
Contract Detail	PROVIDENCE HEALTH & SERVICES - OREGON	MEDICAL OFFICE BUILDING PHARMACY	9155 SOUTHWEST BARNES ROAD	PORTLAND	OR	97225	01/04/2017	04/01/2017	04/01/2019	04/15/2020
Contract Detail	PROVIDENCE HEALTH & SERVICES - OREGON	PROVIDENCE TANASBOURNE PHARMACY	10670 NE CORNELL RD STE 102	HILLSBORO	OR	97124-9221	01/04/2017	04/01/2017	04/01/2017	10/16/2020
Contract Detail	PROVIDENCE HEALTH & SERVICES - OREGON	PROVIDENCE SPECIALTY PHARMACY SERVICES -	6410 NE HALSEY ST STE 400	PORTLAND	OR	97213-4759	07/17/2017	10/01/2017		10/01/2017
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #2993	13434 COLTON PLACE	OREGON CITY	OR	97045	04/03/2019	07/01/2019		07/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1627	3930 SE POWELL BLVD	PORTLAND	OR	97202	04/03/2019	07/01/2019		07/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1478	15570 SW PACIFIC HWY	TIGARD	OR	97224	04/03/2019	07/01/2019		07/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #0509	5920 NE MLK BLVD	PORTLAND	OR	97211	04/03/2019	07/01/2019		07/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1627	3930 SE POWELL BLVD	PORTLAND	OR	97202	04/03/2019	07/01/2019		07/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1612	1100 NE BROADWAY ST	PORTLAND	OR	97232	04/03/2019	07/01/2019		07/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1203	2525 SE TV HWY	HILLSBORO	OR	97123	04/03/2019	07/01/2019		07/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1612	1100 NE BROADWAY ST	PORTLAND	OR	97232	04/03/2019	07/01/2019		07/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #2631	14555 SW TEAL BLVD	BEAVERTON	OR	97007	04/03/2019	07/01/2019		07/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1073	6194 SW MURRAY BLVD	BEAVERTON	OR	97008	04/03/2019	07/01/2019		07/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1751	1525 W MAIN ST	MOLALLA	OR	97038	04/03/2019	07/01/2019		07/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1447	6901 NE SANDY BLVD	PORTLAND	OR	97213	04/03/2019	07/01/2019		07/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #0382	3527 SE 122ND AVE	PORTLAND	OR	97236	04/03/2019	07/01/2019		07/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #2690	4320 SE KING ROAD	MILWAUKIE	OR	97222	04/03/2019	07/01/2019		07/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1260	401 S ROOSEVELT DR	SEASIDE	OR	97138-6738	04/03/2019	07/01/2019		07/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #2448	1010 SW JEFFERSON ST	PORTLAND	OR	97201-3425	07/15/2020	10/01/2020		10/01/2020
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5345	622 SW ALDER STREET	PORTLAND	OR	97205	01/15/2020	04/01/2020		04/01/2020
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #6467	600 NW 10TH AVENUE	PORTLAND	OR	97209	01/15/2020	04/01/2020		04/01/2020
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5346	1814 NE 41ST AVENUE	PORTLAND	OR	97212	01/15/2020	04/01/2020		04/01/2020
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5357	514 NE 181ST AVENUE	PORTLAND	OR	97230	01/15/2020	04/01/2020		04/01/2020
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5352	10860 S.E. OAK STREET	MILWAUKIE	OR	97222	01/15/2020	04/01/2020		04/01/2020
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/15/2020	10/01/2020		10/01/2020
Contract Detail	WAL-MART PHARMACY 10-2552	4200 SE 82ND AVENUE		PORTLAND	OR	97266	07/15/2020	10/01/2020		10/01/2020
Contract Detail	WAL-MART PHARMACY 10-2927	23500 NE SANDY BLVD		WOOD VILLAGE	OR	97060	07/15/2020	10/01/2020		10/01/2020
Contract Detail	WAL-MART PHARMACY 10-3178	2444 E POWELL BLVD		GRESHAM	OR	97080	07/15/2020	10/01/2020		10/01/2020
Contract Detail	WAL-MART PHARMACY 10-5440	10000 SOUTHEAST 82ND AVENUE		HAPPY VALLEY	OR	97086	07/15/2020	10/01/2020		10/01/2020
Contract Detail	WAL-MART PHARMACY 10-5627	3900 W POWELL BLVD		GRESHAM	OR	97030	07/15/2020	10/01/2020		10/01/2020
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/15/2020	10/01/2020		10/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03838	1950 NE BURNSIDE RD	GRESHAM	OR	97030	01/17/2017	04/01/2017		04/20/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03890	940 SE CESAR E CHAVEZ BLVD	PORTLAND	OR	97214	01/17/2017	04/01/2017		04/20/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03925	3 NE 82ND AVE	PORTLAND	OR	97220	01/17/2017	04/01/2017		04/20/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06426	12335 NE GLISAN ST	PORTLAND	OR	97230	01/17/2017	04/01/2017		04/20/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 16259	17979 NE GLISAN ST	PORTLAND	OR	97230	01/17/2017	04/01/2017		04/20/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04296	3909 SE HOLGATE BLVD	PORTLAND	OR	97202	01/17/2017	04/01/2017		04/20/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05952	7280 SW BEAVERTON-HILLSDALE HWY	PORTLAND	OR	97225	01/17/2017	04/01/2017		04/20/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07119	5420 NE 33RD AVE	PORTLAND	OR	97211-7404	01/17/2017	04/01/2017		04/20/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04353	4325 82ND SE	PORTLAND	OR	97266	01/17/2017	04/01/2017		04/20/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06140	1620 NE GRAND AVE	PORTLAND	OR	97232	01/17/2017	04/01/2017		04/20/2017
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21151	1215 NW 23RD AVE	PORTLAND	OR	97210	04/06/2018	07/01/2018		04/06/2018
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	01/17/2017	04/01/2017	10/01/2017	10/02/2017
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	10/02/2017	01/01/2018		10/02/2017
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	01/17/2017	04/01/2017		04/20/2017
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	01/17/2017	04/01/2017	10/01/2021	01/10/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	01/17/2017	04/01/2017		04/20/2017
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	01/17/2017	04/01/2017		04/20/2017
Contract Detail	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	10/02/2017	01/01/2018		10/02/2017

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH380061A	Child	DSH	PROVIDENCE PORTLAND MEDICAL CENTER	PROV CANCER CENTER INFUSION - WEST	9135 SW BARNES RD STE 263	PORTLAND	OR	Active
DSH380061B	Child	DSH	PROVIDENCE PORTLAND MEDICAL CENTER	Anticoagulation Clinic	5050 NE Hoyt St	Portland	OR	Active
DSH380061C	Child	DSH	PROVIDENCE PORTLAND MEDICAL CENTER	Arthritis Center	5050 NE Hoyt St	Portland	OR	Active
DSH380061D	Child	DSH	PROVIDENCE PORTLAND MEDICAL CENTER	PROVIDENCE CANCER INSTITUTE INFUSION - NEWBERG - Oncology	1000 Providence Drive	Newberg	OR	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Insert	Recertification		PROVIDENCE PORTLAND MEDICAL CENTER 4805 NE GLISAN ST PORTLAND, OR 97213	9/4/2024 6:51 AM
Details	Last Recertification Date	Update	Recertification	9/7/2023 3:21:50 PM	9/4/2024 6:51:33 AM	9/4/2024 6:51 AM
Addresses	Main Address	Update	Change Request	4805 NE GLISAN PORTLAND, OR 97213	4805 NE GLISAN ST PORTLAND, OR 97213	7/25/2024 7:46 AM
Details	Last Recertification Date	Update	Recertification	8/31/2022 3:13:48 PM	9/7/2023 3:21:50 PM	9/7/2023 3:21 PM
Contacts	Authorizing Official	Update	Change Request	Olson, Eric Chief Financial Officer Providence Portland Medical Center 5032156241	Buzbee, Kate CFO Providence 9713004268	9/30/2022 7:07 AM
Details	Last Recertification Date	Update	Recertification	8/16/2021 11:41:42 AM	8/31/2022 3:13:48 PM	8/31/2022 3:13 PM
Details	Last Recertification Date	Update	Recertification	8/31/2020 12:37:00 PM	8/16/2021 11:41:42 AM	8/16/2021 11:41 AM
Contacts	Primary Contact	Update	Profile Change Request	Ovenell, Mac 340B Program Manager Providence Health and Services 5098608643	Ovenell, Mac 340B Director Providence Health and Services 5098608643	8/5/2021 11:16 AM
Contacts	Primary Contact	Update	Profile Change Request	Ovenell, Mac 340B Program Manager Providence Health and Services 5038937383	Ovenell, Mac 340B Program Manager Providence Health and Services 5098608643	6/24/2021 12:03 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1003991845	8/31/2020 12:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		WA	8/31/2020 12:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1003991845	8/31/2020 12:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/31/2020 12:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1003991845	8/31/2020 12:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		AK	8/31/2020 12:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1003991845	8/31/2020 12:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		ID	8/31/2020 12:37 PM
Medicaid Billing	NPI: State	Update	Recertification		OR	8/31/2020 12:37 PM
Details	Last Recertification Date	Update	Recertification	9/2/2019 7:15:59 PM	8/31/2020 12:37:00 PM	8/31/2020 12:37 PM
Contacts	Primary Contact	Update	Change Request	Dawson, Michael Regional 340b Program Manager Providence 5038936205	Ovenell, Mac 340B Program Manager Providence Health and Services 5038937383	3/10/2020 12:41 PM
Contacts	Primary Contact	Update	Change Request	Free, Joshua Reg. Dir. Business Services Providence Hood River Memorial Hospital 5038936201	Dawson, Michael Regional 340b Program Manager Providence 5038936205	11/15/2019 1:24 PM
Details	Last Recertification Date	Update	Recertification	8/22/2018 3:51:41 PM	9/2/2019 7:15:59 PM	9/2/2019 7:15 PM
Contacts	Primary Contact	Update	Change Request	Thompson, Jacob Regional Director, Pharmacy Operations & Compliance Providence Health & Services 5038936247	Free, Joshua Reg. Dir. Business Services Providence Hood River Memorial Hospital 5038936201	8/5/2019 4:03 PM
Details	Last Recertification Date	Update	Recertification	11/6/2017 2:11:33 PM	8/22/2018 3:51:41 PM	8/22/2018 3:51 PM
Contacts	Authorizing Official	Update	Change Request	Farnham, Krista Interim Chief Executive Officer Providence Portland Medical Center 5032157323	Olson, Eric Chief Financial Officer Providence Portland Medical Center 5032156241	6/14/2018 1:31 PM
Contacts	Authorizing Official	Update	Change Request	Gaden, Paul Chief Executive Providence Portland Medical Center 5032158603	Farnham, Krista Interim Chief Executive Officer Providence Portland Medical Center 5032157323	3/22/2018 2:12 PM
Contacts	Primary Contact	Update	Change Request	Buxell, Shannon Pharmacy Operations Manager Providence Health & Services 5032156404	Thompson, Jacob Regional Director, Pharmacy Operations & Compliance Providence Health & Services 5038936247	12/22/2017 9:50 PM
Details	Last Recertification Date	Update	Recertification	8/22/2016 12:00:00 AM	11/6/2017 2:11:33 PM	11/6/2017 2:11 PM
Contacts	Authorizing Official	Update		Gaden, Paul Chief Executive 5032158603	Gaden, Paul Chief Executive Providence Portland Medical Center 5032158603	9/26/2017 5:12 PM
Contacts	Signed By	Update		Gaden, Paul Chief Executive 5032158603	Gaden, Paul Chief Executive Providence Portland Medical Center 5032158603	9/26/2017 5:12 PM
Contacts	Primary Contact	Update		Buxell, Shannon Pharmacy Operations Manager 5032156404	Buxell, Shannon Pharmacy Operations Manager Providence Health & Services 5032156404	9/25/2017 2:01 PM
Contacts	Authorizing Official	Insert			Gaden, Paul Chief Executive 5032158603	7/17/2017 3:40 PM
Contacts	Signed By	Insert			Gaden, Paul Chief Executive 5032158603	7/17/2017 3:40 PM
Contacts	Primary Contact	Update		pierce, Tammy Director of Pharmacy 5032156557	Buxell, Shannon Pharmacy Operations Manager 5032156404	4/20/2017 5:28 PM
Addresses	Main Address	Insert			4805 NE GLISAN PORTLAND, OR 97213	4/20/2017 5:28 PM
Addresses	Shipping Address	Insert			Safecor Health 4060 Business Park Drive Columbus, OH 43204	4/20/2017 5:28 PM
Details	Last Recertification Date	Update		8/7/2015 12:00:00 AM	8/22/2016 12:00:00 AM	8/22/2016 4:35 PM
Contacts	Primary Contact	Insert			pierce, Tammy Director of Pharmacy 5032156557	8/7/2015 4:43 PM
Details	Last Recertification Date	Update			8/7/2015 12:00:00 AM	8/7/2015 4:43 PM
Dates	Participating Approval Date	Update			5/20/2015 12:00:00 AM	5/20/2015 2:20 PM
Details	State	Update		Pending	Active	5/20/2015 2:20 PM
Dates	Start Date	Update			7/1/2015 12:00:00 AM	5/20/2015 2:20 PM
Details	340B ID	Update		ONLINE_REG_50842	DSH380061	4/27/2015 11:40 AM
Details	340B ID	Update			ONLINE_REG_50842	4/8/2015 12:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/8/2015 12:45 PM
Medicaid Billing	Medicaid: Number	Insert			150300	4/8/2015 12:45 PM
Medicaid Billing	Medicaid: State	Insert			OR	4/8/2015 12:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/8/2015 12:45 PM
Medicaid Billing	Medicaid: Number	Insert			1000242	4/8/2015 12:45 PM
Medicaid Billing	Medicaid: State	Insert			WA	4/8/2015 12:45 PM
Medicaid Billing	NPI: Number	Insert			1003991845	4/8/2015 12:45 PM
Details	Last Recertification Date	Insert				4/8/2015 12:45 PM
Details	Grant Number	Insert				4/8/2015 12:45 PM
Details	340B ID	Insert				4/8/2015 12:45 PM
Details	Is Authorizing Official EHB Data	Insert				4/8/2015 12:45 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/8/2015 12:45 PM
Details	Medicare Provider Number	Insert			380061	4/8/2015 12:45 PM
Details	Entity Name	Insert			PROVIDENCE PORTLAND MEDICAL CENTER	4/8/2015 12:45 PM
Details	Program Code	Insert			DSH	4/8/2015 12:45 PM
Details	Entity Subname	Insert				4/8/2015 12:45 PM
Dates	Participating Approval Date	Insert				4/8/2015 12:45 PM
Details	State	Insert			Pending	4/8/2015 12:45 PM
Dates	Registration Date	Insert			4/8/2015 12:00:00 AM	4/8/2015 12:45 PM
Dates	Signed By Date	Insert			4/8/2015 12:00:00 AM	4/8/2015 12:45 PM
Dates	Start Date	Insert				4/8/2015 12:45 PM
Terminations	Termination Comments	Insert				4/8/2015 12:45 PM
Terminations	Termination Date	Insert				4/8/2015 12:45 PM
Terminations	Termination Effective Date	Insert				4/8/2015 12:45 PM
Terminations	Termination Reason	Insert				4/8/2015 12:45 PM