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CYSTIC FIBROSIS SERVICES, LLC
DSH500014 PROVIDENCE HEALTH & SERVICES - WASHINGTON
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Covered Entity Details
Entity Name
PROVIDENCE HEALTH & SERVICES - WASHINGTON
Subdivision Name
PROVIDENCE REGIONAL MEDICAL CENTER EVERETT COLBY CAMPUS
Type
Disproportionate Share Hospital
340B ID
DSH500014
Entity Address
1321 COLBY AVENUE
EVERETT, WA 98201
Medicare Provider Number
500014
Participating Start Date
4/1/2005
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
10/14/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/7/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Scott Combs, CFO
(425) 261-4044
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/14/2019
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