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PROCARE PHARMACY, L.L.C.
DSH500019 PROVIDENCE HEALTH AND SERVICES - WASHINGTON PROVIDENCE CENTRALIA
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Covered Entity Details
Entity Name
PROVIDENCE HEALTH AND SERVICES - WASHINGTON PROVIDENCE CENTRALIA
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500019
Entity Address
914 SOUTH SCHEUBER ROAD
CENTRALIA, WA 98531
Medicare Provider Number
500019
Participating Start Date
1/1/2007
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
PROCARE PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #2926
1001 MADISON ST.
SEATTLE, WA 98104
Pharmacy Comments
Contract Details
Approval Date
10/15/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Denise Marroni, CFO SWR
(360) 493-5203
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/15/2019
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