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AETNA SPECIALTY PHARMACY, LLC
DSH380061 PROVIDENCE PORTLAND MEDICAL CENTER
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Covered Entity Details
Entity Name
PROVIDENCE PORTLAND MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380061
Entity Address
4805 NE GLISAN ST
PORTLAND, OR 97213
Medicare Provider Number
380061
Participating Start Date
7/1/2015
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
AETNA SPECIALTY PHARMACY, LLC
Pharmacy Address
503 SUNPORT LN
ORLANDO, FL 32809-7874
Pharmacy Comments
Contract Details
Approval Date
4/14/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Eric Olson, Chief Financial Officer
(503) 215-6241
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/14/2019
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