Contract Pharmacy Details

PEACEHEALTH ST JOHN MEDICAL CENTER PHARM
DSH500041 PEACEHEALTH ST. JOHN MEDICAL CENTER

Covered Entity Details

Entity Name

PEACEHEALTH ST. JOHN MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH500041

Entity Address

1615 DELAWARE ST
LONGVIEW, WA 98632

Medicare Provider Number

500041

Participating Start Date

7/1/2004

Last Recertification Date

8/19/2024

Pharmacy Details

Pharmacy Name

PEACEHEALTH ST JOHN MEDICAL CENTER PHARM

Pharmacy Address

1615 DELAWARE ST
LONGVIEW, WA 98632-2367

Pharmacy Comments

Contract Details

Approval Date

4/2/2021

Contract Begin Date

7/1/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

5/31/2022
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Sean Gregory, Chief Executive
(360) 514-2082

Contract Pharmacy Representative

PeaceHealth
Charmaine Mode, Mgr, Pharmacy
(360) 414-7656

Signed By Date

4/2/2021

340B Drug Pricing Program Database