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FRED MEYER
DSH380004 PROVIDENCE ST. VINCENT MEDICAL CENTER
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Covered Entity Details
Entity Name
PROVIDENCE ST. VINCENT MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380004
Entity Address
9205 SW BARNES RD
PORTLAND, OR 97225
Medicare Provider Number
380004
Participating Start Date
1/1/2016
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
FRED MEYER
Pharmacy Address
19200 S.W. MARTINAZZI AVENUE
TUALATIN, OR 97062
Pharmacy Comments
Contract Details
Approval Date
7/12/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Nancy S. Roberts, Chief Operating Officer
(503) 216-4609
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/12/2019
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