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FRED MEYER STORES INC
DSH380060 Portland Adventist Medical Center dba Adventist Health Portland
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Covered Entity Details
Entity Name
Portland Adventist Medical Center dba Adventist Health Portland
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380060
Entity Address
10123 SE Market Street
Portland, OR 97216
Medicare Provider Number
380060
Participating Start Date
10/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
FRED MEYER STORES INC
Pharmacy Address
FRED MEYER PHARMACY #242
1839 MOLALLA AVENUE
OREGON CITY, OR 97045
Pharmacy Comments
Contract Details
Approval Date
1/12/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Donald E. Welch, CFO
(503) 261-4406
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
1/12/2021
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