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FRED MEYER INC
DSH380017 LEGACY GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
LEGACY GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380017
Entity Address
1015 NW 22ND AVENUE
PORTLAND, OR 97210
Medicare Provider Number
380017
Participating Start Date
10/1/2016
Last Recertification Date
9/2/2024
Pharmacy Details
Pharmacy Name
FRED MEYER INC
Pharmacy Address
6850 N LOMBARD
PORTLAND, OR 97203
Pharmacy Comments
Contract Details
Approval Date
4/10/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Anna Loomis, SVP Chief Financial Officer
(503) 415-5730
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
4/10/2020
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