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PEACEHEALTH SOUTHWEST PHARMACY AT MEDICA
DSH500050 PeaceHealth Southwest Medical Center
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Covered Entity Details
Entity Name
PeaceHealth Southwest Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500050
Entity Address
400 NE Mother Joseph Place
VANCOUVER, WA 98664
Medicare Provider Number
500050
Participating Start Date
4/1/2005
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
PEACEHEALTH SOUTHWEST PHARMACY AT MEDICA
Pharmacy Address
420 NE MOTHER JOSEPH PL
VANCOUVER, WA 98664-3200
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
Austin Horner, Mgr, Pharmacy
(360) 514-6087
Signed By Date
4/2/2021
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