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PROCARE PHARMACY, L.L.C.
DSH380025 LEGACY MOUNT HOOD MEDICAL CENTER
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Covered Entity Details
Entity Name
LEGACY MOUNT HOOD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380025
Entity Address
24800 SE STARK ST
GRESHAM, OR 97030
Medicare Provider Number
380025
Participating Start Date
7/1/2007
Last Recertification Date
9/2/2024
Pharmacy Details
Pharmacy Name
PROCARE PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #11280
538 SW 4TH AVENUE
PORTLAND, OR 97204
Pharmacy Comments
Contract Details
Approval Date
4/10/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/17/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Anna Loomis, SVP Chief Financial Officer
(503) 415-5730
Contract Pharmacy Representative
CVS Health
Christian Reid, 340B Program Director
(401) 770-2118
Signed By Date
4/10/2020
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