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DIPLOMAT SPECIALTY PHARMACY
CAH381308-00 Salem Health West Valley
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Covered Entity Details
Entity Name
Salem Health West Valley
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH381308-00
Entity Address
525 SE WASHINGTON STREET
DALLAS, OR 97338-0378
Medicare Provider Number
381308
Participating Start Date
1/1/2016
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
DIPLOMAT SPECIALTY PHARMACY
Pharmacy Address
1370 BUSCH PKWY
BUFFALO GROVE, IL 60089-4505
Pharmacy Comments
Contract Details
Approval Date
4/6/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/6/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
Josh Free, Chief Pharmacy Officer
(503) 814-2773
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/6/2020
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