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FRED MEYER STORES
DSH020001 PROVIDENCE ALASKA MEDICAL CENTER
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Covered Entity Details
Entity Name
PROVIDENCE ALASKA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH020001
Entity Address
3200 PROVIDENCE DRIVE
ANCHORAGE, AK 99508
Medicare Provider Number
020001
Participating Start Date
7/1/2005
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
FRED MEYER STORES
Pharmacy Address
DBA: FRED MEYER
7701 DEBARR RD
ANCHORAGE, AK 99504-1872
Pharmacy Comments
Contract Details
Approval Date
7/15/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/25/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
AMY MILLER, Chief Financial Officer, ALASKA
(907) 212-6503
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/15/2021
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