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WAL-MART CENTRAL FILL 10-2670
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
WAL-MART CENTRAL FILL 10-2670
Pharmacy Address
608 SPRING HILL DR # 3 SUITE 300
SPRING, TX 77386
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
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/15/2020
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