Contract Pharmacy Details

DIPLOMAT SPECIALTY PHARMACY
DSH500003 SKAGIT VALLEY HOSPITAL

Covered Entity Details

Entity Name

SKAGIT VALLEY HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH500003

Entity Address

1415 EAST KINCAID
MOUNT VERNON, WA 98274-4126

Medicare Provider Number

500003

Participating Start Date

7/1/2006

Last Recertification Date

8/21/2024

Pharmacy Details

Pharmacy Name

DIPLOMAT SPECIALTY PHARMACY

Pharmacy Address

4100 S SAGINAW ST
STE D
FLINT, MI 48507-2683

Pharmacy Comments

04/09/2012 update address and name (added suite)

Contract Details

Approval Date

7/13/2020

Contract Begin Date

8/4/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/24/2022
Ownership change

Contacts

Covered Entity Signing Official

Paul Ishizuka, CFO
(360) 814-5838

Contract Pharmacy Representative

Optum
Dave Miller, Account Manager
(847) 917-1731

Signed By Date

7/13/2020