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DIPLOMAT SPECIALTY PHARMACY
CAH381323-00 MID-VALLEY HEALTHCARE, INC. DBA SAMARITAN LEBANON COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
MID-VALLEY HEALTHCARE, INC. DBA SAMARITAN LEBANON COMMUNITY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH381323-00
Entity Address
525 N. SANTIAM HWY
LEBANON, OR 97355
Medicare Provider Number
381323
Participating Start Date
8/4/2010
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
DIPLOMAT SPECIALTY PHARMACY
Pharmacy Address
15211 VANOWEN ST
STE 301
VAN NUYS, CA 91405
Pharmacy Comments
Contract Details
Approval Date
10/11/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2021
Ownership change
Contacts
Covered Entity Signing Official
Daniel Smith, VP Finance/CFO
(541) 768-5390
Contract Pharmacy Representative
Diplomat Specialty Pharmancy
Jasmen Barzivand, Pharmacist in Charge
(818) 988-1288
Signed By Date
10/11/2019
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