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CREDENA HEALTH PHARMACY CENTRALIA
DSH500019 PROVIDENCE HEALTH AND SERVICES - WASHINGTON PROVIDENCE CENTRALIA
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Covered Entity Details
Entity Name
PROVIDENCE HEALTH AND SERVICES - WASHINGTON PROVIDENCE CENTRALIA
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500019
Entity Address
914 SOUTH SCHEUBER ROAD
CENTRALIA, WA 98531
Medicare Provider Number
500019
Participating Start Date
1/1/2007
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
CREDENA HEALTH PHARMACY CENTRALIA
Pharmacy Address
1800 COOKS HILL RD STE P
CENTRALIA, WA 98531-9162
Pharmacy Comments
Contract Details
Approval Date
9/4/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Denise Marroni, CFO SWR
(360) 493-5203
Contract Pharmacy Representative
Providence
Tammy Pierce, Director of Pharmacy
(503) 962-1700
Signed By Date
9/4/2020
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