Contract Pharmacy Details

CREDENA HEALTH PHARMACY SACRED HEART
DSH500019 PROVIDENCE HEALTH AND SERVICES - WASHINGTON PROVIDENCE CENTRALIA

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

8/28/2023

Pharmacy Name

CREDENA HEALTH PHARMACY SACRED HEART

Pharmacy Address

101 W 8TH AVE STE 207653
SPOKANE, WA 99204-2307

Pharmacy Comments

Approval Date

1/15/2020

Contract Begin Date

4/1/2020

Carve-In Effective Date

Contract Comments

Covered Entity Signing Official

Denise Marroni, CFO SWR
(360) 493-5203

Signed By Date

1/15/2020

Contract Pharmacy Representative

Providence Heath & Services
Eric H Reimer, Pharmacist in Charge
(509) 474-4569