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FRED MEYER INC
RRC380014-00 GOOD SAMARITAN HOSPITAL CORVALLIS
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Covered Entity Details
Entity Name
GOOD SAMARITAN HOSPITAL CORVALLIS
Subdivision Name
Type
Rural Referral Center
340B ID
RRC380014-00
Entity Address
3600 NW SAMARITAN DRIVE
CORVALLIS, OR 97330
Medicare Provider Number
380014
Participating Start Date
10/1/2018
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
FRED MEYER INC
Pharmacy Address
PHARMACY
777 NW KINGS BLVD
CORVALLIS, OR 97330
Pharmacy Comments
Contract Details
Approval Date
7/15/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/8/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Daniel Smith, VP Finance/CFO
(541) 768-5390
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/15/2019
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