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DSH500014D PROV REGL MED CENTER EVERETT (Terminated)
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Main Details
Name
PROV REGL MED CENTER EVERETT
Subdivision Name
WOUND CLINIC
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH500014D
Medicare Provider Number
500014
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/5/2015
Participating Start Date
1/1/2016
Participating Approval Date
11/17/2015
Last Recertification Date
8/11/2016
Termination Date
Termination Reason
7/1/2017
Site closure
Contacts
Authorizing Official
Providence Health & Services Washington
Scott Combs, CFO
(425) 261-4044
Primary Contact
Providence Health & Services Washington
Eric Werttemberger, Director of Pharmacy
(425) 261-3530
Addresses
Street Address
1330 ROCKEFELLER AVE
STE 540
EVERETT, WA 98201-1677
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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