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CREDENA HEALTH PHARMACY PPMC PLAZA
DSH380038 PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER
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Covered Entity Details
Entity Name
PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380038
Entity Address
1500 DIVISION STREET
OREGON CITY, OR 97045
Medicare Provider Number
380038
Participating Start Date
7/1/2015
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
CREDENA HEALTH PHARMACY PPMC PLAZA
Pharmacy Address
5050 NE HOYT ST STE 142
PORTLAND, OR 97213
Pharmacy Comments
Contract Details
Approval Date
4/12/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Russell P. Reinhard, Chief Executive
(503) 657-6915
Contract Pharmacy Representative
Providence St. Joseph Health
Glenn W Wachter, Outpatient Ops Strat Exec Dir, Pharmacy
(503) 962-1743
Signed By Date
4/12/2019
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