Contract Pharmacy Details

MEYER
DSH380075 PROVIDENCE MEDFORD MEDICAL CENTER

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

MEYER

Pharmacy Address

2655 SHASTA WAY
KLAMATH FALLS, OR 97603

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

340B Drug Pricing Program Database