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DSH380017 LEGACY GOOD SAMARITAN HOSPITAL (Active)
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Main Details
Name
LEGACY GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH380017
Medicare Provider Number
380017
Additional Details
Current Program Status
Active
Registration Date
7/5/2016
Participating Start Date
10/1/2016
Participating Approval Date
8/12/2016
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
1015 NW 22ND AVENUE
PORTLAND, OR 97210
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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May 2025
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