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FRED MEYER STORES, INC
DSH500044 DEACONESS MEDICAL CENTER
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Covered Entity Details
Entity Name
DEACONESS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500044
Entity Address
800 W 5TH AVENUE
SPOKANE, WA 99204
Medicare Provider Number
500044
Participating Start Date
1/1/2019
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
FRED MEYER STORES, INC
Pharmacy Address
FRED MEYER PHARMACY 351
15609 EAST SPRAGUE AVE
SPOKANE VALLEY, WA 99037
Pharmacy Comments
Contract Details
Approval Date
4/7/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/30/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Florence Chang, President
(253) 403-7355
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
4/7/2020
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