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CVS/SPECIALTY OR CARELONRX SPECIALTY PHA
DSH380061 PROVIDENCE PORTLAND MEDICAL CENTER
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Covered Entity Details
Entity Name
PROVIDENCE PORTLAND MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380061
Entity Address
4805 NE GLISAN ST
PORTLAND, OR 97213
Medicare Provider Number
380061
Participating Start Date
7/1/2015
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
CVS/SPECIALTY OR CARELONRX SPECIALTY PHA
Pharmacy Address
CAREMARK, LLC
1001 SPINKS ROAD, STE 280
FLOWER MOUND, TX 75028
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
Eric Olson, Chief Financial Officer
(503) 215-6241
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/15/2020
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