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VIRGINIA MASON GEORGETOWN PHARMACY
RRC500039-00 ST. MICHAEL MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. MICHAEL MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC500039-00
Entity Address
1800 NW MYHRE ROAD
SILVERDALE, WA 98383
Medicare Provider Number
500039
Participating Start Date
1/1/2018
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
VIRGINIA MASON GEORGETOWN PHARMACY
Pharmacy Address
5959 CORSON AVE S
STE C-1
SEATTLE, WA 98108
Pharmacy Comments
Contract Details
Approval Date
4/14/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/3/2023
Ownership change
Contacts
Covered Entity Signing Official
Mike Fitzgerald, CFO
(253) 680-4005
Contract Pharmacy Representative
St. Michael Medical Center (formerly Harrison Medical Center)
Charles C Ho, Director of Pharmacy
(714) 658-2517
Signed By Date
4/14/2021
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