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PROVIDENCE INFUSION AND PHARMACY SERVICE
DSH500077 PROVIDENCE HEALTH & SERVICES-WASHINGTON
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Covered Entity Details
Entity Name
PROVIDENCE HEALTH & SERVICES-WASHINGTON
Subdivision Name
PROVIDENCE HOLY FAMILY HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH500077
Entity Address
5633 NORTH LIDGERWOOD STREET
SPOKANE, WA 99208
Medicare Provider Number
500077
Participating Start Date
7/1/2010
Last Recertification Date
9/11/2024
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
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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