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FRED MEYER PHARMACY #126
DSH380075 PROVIDENCE MEDFORD MEDICAL CENTER
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Covered Entity Details
Entity Name
PROVIDENCE MEDFORD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380075
Entity Address
1111 CRATER LAKE AVENUE
MEDFORD, OR 97504
Medicare Provider Number
380075
Participating Start Date
7/1/2015
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
FRED MEYER PHARMACY #126
Pharmacy Address
1101 GRANTS PASS PKWY
GRANTS PASS, OR 97526-2333
Pharmacy Comments
Contract Details
Approval Date
7/14/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Christopher Pizzi, Chief Operating Officer
(541) 732-5195
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/14/2019
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