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EVERGREEN PHARMACEUTICAL,LLC
CAH381308-00 Salem Health West Valley
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Covered Entity Details
Entity Name
Salem Health West Valley
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH381308-00
Entity Address
525 SE WASHINGTON STREET
DALLAS, OR 97338-0378
Medicare Provider Number
381308
Participating Start Date
1/1/2016
Last Recertification Date
9/3/2024
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
7/15/2021
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
Caremark L.L.C.
Christian reid, 340b Program Director
(401) 770-2118
Signed By Date
7/15/2021
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