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EVERGREEN PHARMACEUTICAL LLC
RRC500024-00 PROVIDENCE ST. PETER HOSPITAL
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Covered Entity Details
Entity Name
PROVIDENCE ST. PETER HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC500024-00
Entity Address
413 LILLY ROAD NE
OLYMPIA, WA 98506
Medicare Provider Number
500024
Participating Start Date
4/1/2020
Last Recertification Date
9/11/2024
Pharmacy Details
Pharmacy Name
EVERGREEN PHARMACEUTICAL LLC
Pharmacy Address
OMNICARE OF SEATTLE
12674 GATEWAY DR S
TUKWILA, WA 98168-3307
Pharmacy Comments
Contract Details
Approval Date
7/15/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Denise Marroni, CFO SWR
(360) 493-5203
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/15/2021
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