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WALGREEN CO.
DSH500019 PROVIDENCE HEALTH AND SERVICES - WASHINGTON PROVIDENCE CENTRALIA
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Covered Entity Details
Entity Name
PROVIDENCE HEALTH AND SERVICES - WASHINGTON PROVIDENCE CENTRALIA
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500019
Entity Address
914 SOUTH SCHEUBER ROAD
CENTRALIA, WA 98531
Medicare Provider Number
500019
Participating Start Date
1/1/2007
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 06917
8333 MARTIN WAY EAST
LACEY, WA 98516-5808
Pharmacy Comments
Contract Details
Approval Date
4/15/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Denise Marroni, CFO SWR
(360) 493-5203
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/15/2020
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