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FRED MEYER
DSH380038 PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER
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Covered Entity Details
Entity Name
PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380038
Entity Address
1500 DIVISION STREET
OREGON CITY, OR 97045
Medicare Provider Number
380038
Participating Start Date
7/1/2015
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
FRED MEYER
Pharmacy Address
CLACKAMAS STORE
16301 S E 82ND DRIVE
CLACKAMAS, OR 97015
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Russell P. Reinhard, Chief Executive
(503) 657-6915
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/15/2020
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