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APOTHECARY AT SALMON CREEK
DSH380017 LEGACY GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
LEGACY GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380017
Entity Address
1015 NW 22ND AVENUE
PORTLAND, OR 97210
Medicare Provider Number
380017
Participating Start Date
10/1/2016
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
4/2/2019
Contract Begin Date
7/1/2019
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 Salmon Creek Hospital
Ryan Erlewine, Director of Pharmacy Services
(360) 487-3454
Signed By Date
4/2/2019
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