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APOTHECARY AT SALMON CREEK
DSH380025 LEGACY MOUNT HOOD MEDICAL CENTER
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Covered Entity Details
Entity Name
LEGACY MOUNT HOOD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380025
Entity Address
24800 SE STARK ST
GRESHAM, OR 97030
Medicare Provider Number
380025
Participating Start Date
7/1/2007
Last Recertification Date
9/2/2024
Pharmacy Details
Pharmacy Name
APOTHECARY AT SALMON CREEK
Pharmacy Address
2121 NE 139TH ST STE 310
VANCOUVER, WA 98686
Pharmacy Comments
Contract Details
Approval Date
1/14/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Carol Bradley, SVP and Chief Nursing Officer
(503) 415-5199
Contract Pharmacy Representative
Legacy Health
Kathleen C. Stoner, Vice President Supply Chain and Pharmacy Services
(503) 944-4276
Signed By Date
1/14/2019
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