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WALGREEN CO.
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
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 16259
17979 NE GLISAN ST
PORTLAND, OR 97230
Pharmacy Comments
Contract Details
Approval Date
4/14/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/9/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
Anna Loomis, SVP Chief Financial Officer
(503) 415-5730
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/14/2020
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