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EVERGREEN PHARMACEUTICAL,LLC
DSH380051 Salem Health
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Covered Entity Details
Entity Name
Salem Health
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380051
Entity Address
890 Oak Street SE
Salem, OR 97301
Medicare Provider Number
380051
Participating Start Date
7/1/2012
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
EVERGREEN PHARMACEUTICAL,LLC
Pharmacy Address
DBA OMNICARE OF PORTLAND
11933 NE GLENN WIDING DR
PORTLAND, OR 97220-9099
Pharmacy Comments
Contract Details
Approval Date
7/8/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Josh Free, Chief Pharmacy Officer
(503) 814-2773
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/8/2021
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