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WASHINGTON CVS PHARMACY, L.L.C.
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
WASHINGTON CVS PHARMACY, L.L.C.
Pharmacy Address
CVS PHARMACY # 16694
665 SLEATER KINNEY RD SE
LACEY, WA 98503
Pharmacy Comments
Contract Details
Approval Date
10/14/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Denise Marroni, CFO SWR
(360) 493-5203
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/14/2020
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