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OREGON CVS PHARMACY, L.L.C.
DSH380056 SANTIAM MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SANTIAM MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380056
Entity Address
1401 NORTH 10TH AVE
STAYTON, OR 97383
Medicare Provider Number
380056
Participating Start Date
7/1/2021
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
OREGON CVS PHARMACY, L.L.C.
Pharmacy Address
CVS PHARMACY # 16154
3790 CENTER ST NE
SALEM, OR 97301
Pharmacy Comments
Contract Details
Approval Date
7/14/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/12/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Maggie Ann Hudson, CEO
(503) 769-9236
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/14/2021
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