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PROVIDENCE HEALTH & SERVICES - OREGON
RWIID97232 Oregon Health Authority
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Covered Entity Details
Entity Name
Oregon Health Authority
Subdivision Name
ADAP / CAREAssist
Type
Ryan White Part B ADAP Direct Purchase
340B ID
RWIID97232
Entity Address
800 NE Oregon St.
Suite 1105
Portland, OR 97232
Grant Number
X07HA00007
Participating Start Date
10/1/2011
Last Recertification Date
2/25/2025
Pharmacy Details
Pharmacy Name
PROVIDENCE HEALTH & SERVICES - OREGON
Pharmacy Address
PROVIDENCE TANASBOURNE PHARMACY
10670 NE CORNELL RD STE 102
HILLSBORO, OR 97124-9221
Pharmacy Comments
Contract Details
Approval Date
4/5/2021
Contract Begin Date
5/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/9/2021
Agreement registered in error
Contacts
Covered Entity Signing Official
Annick Julia Benson-Scott, HIV/STD/TB Section Manager
(971) 673-0142
Contract Pharmacy Representative
Credena Health LLC
Michael Fry, Manager
(503) 216-9020
Signed By Date
4/5/2021
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