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WASHINGTON CVS PHARMACY, L.L.C.
DSH500041 PEACEHEALTH ST. JOHN MEDICAL CENTER
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Covered Entity Details
Entity Name
PEACEHEALTH ST. JOHN MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500041
Entity Address
1615 DELAWARE ST
LONGVIEW, WA 98632
Medicare Provider Number
500041
Participating Start Date
7/1/2004
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WASHINGTON CVS PHARMACY, L.L.C.
Pharmacy Address
CVS PHARMACY # 16168
205 THREE RIVERS DR
KELSO, WA 98626
Pharmacy Comments
Contract Details
Approval Date
10/2/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Sean Gregory, Chief Executive
(360) 514-2082
Contract Pharmacy Representative
Wellpartner, a CVS Company
Derek Stearns, National Sales Exec
(503) 317-9840
Signed By Date
10/2/2018
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