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PROVIDENCE INFUSION AND PHARMACY SERVICE
DSH500054 PROVIDENCE HEALTH & SERVICES - WASHINGTON
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Covered Entity Details
Entity Name
PROVIDENCE HEALTH & SERVICES - WASHINGTON
Subdivision Name
PROVIDENCE SACRED HEART MEDICAL CENTER AND CHILDREN'S HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH500054
Entity Address
101 WEST 8TH AVENUE
SPOKANE, WA 99204
Medicare Provider Number
500054
Participating Start Date
1/1/2005
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
PROVIDENCE INFUSION AND PHARMACY SERVICE
Pharmacy Address
15918 E EUCLID AVE
SPOKANE VALLEY, WA 99216
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
10/14/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Shelby D Stokoe, CFO Providence Health Care
(509) 474-4949
Contract Pharmacy Representative
Providence Infusion Pharmacy Services
Jason Iltz, Director of Pharmacy Operations
(509) 994-8743
Signed By Date
7/15/2019
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