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ST JOSEPH'S MCAULEY PHARMACY
DSH500011 St. Anne Hospital
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Covered Entity Details
Entity Name
St. Anne Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500011
Entity Address
16251 SYLVESTER RD. SW
BURIEN, WA 98166-0657
Medicare Provider Number
500011
Participating Start Date
4/1/2015
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
ST JOSEPH'S MCAULEY PHARMACY
Pharmacy Address
500 W. THOMAS ROAD
SUITE 190
PHOENIX, AZ 85013
Pharmacy Comments
Contract Details
Approval Date
7/9/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/22/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mike Fitzgerald, CFO
(253) 680-4005
Contract Pharmacy Representative
St. Joseph's Hospital and Medical Center
Greg Blank, Director of Pharmacy
(602) 406-4744
Signed By Date
7/9/2020
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