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DIPLOMAT SPECIALTY PHARMACY OF FT LAUDER
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 OF FT LAUDER
Pharmacy Address
DIPLOMAT SPECIALTY PHARMACY
15471 SW 12TH ST
STE 207
SUNRISE, FL 33326
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
4/7/2021
Business decision by covered entity and/or pharmacy
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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