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FRED MEYER INC
DSH380004 PROVIDENCE ST. VINCENT MEDICAL CENTER
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Covered Entity Details
Entity Name
PROVIDENCE ST. VINCENT MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380004
Entity Address
9205 SW BARNES RD
PORTLAND, OR 97225
Medicare Provider Number
380004
Participating Start Date
1/1/2016
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
FRED MEYER INC
Pharmacy Address
ATTN: PHARMACY
3030 NE WEIDLER
PORTLAND, OR 97232
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
Nancy S. Roberts, Chief Operating Officer
(503) 216-4609
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/15/2020
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