340B Drug Pricing Program Database
DIPLOMAT SPECIALTY PHARMACY
DSH500019 PROVIDENCE HEALTH AND SERVICES - WASHINGTON PROVIDENCE CENTRALIA - information as of 4/25/2025 6:54:44 PM
Covered Entity Details
Entity Name
PROVIDENCE HEALTH AND SERVICES - WASHINGTON PROVIDENCE CENTRALIA
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500019
Entity Address
914 SOUTH SCHEUBER ROAD
CENTRALIA, WA 98531
Medicare Provider Number
500019
Participating Start Date
1/1/2007
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
DIPLOMAT SPECIALTY PHARMACY
Pharmacy Address
G3320 BEECHER RD
FLINT, MI 48532-3614
Pharmacy Comments
Contract Details
Approval Date
10/15/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/7/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Denise Marroni, CFO SWR
(360) 493-5203
Contract Pharmacy Representative
Diplomat Pharmacy Inc.
Stacey Kennedy, Manager
(810) 732-8720
Signed By Date
10/15/2019
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