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PROCARE PHARMACY, L.L.C.
DSH380017 LEGACY GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
LEGACY GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380017
Entity Address
1015 NW 22ND AVENUE
PORTLAND, OR 97210
Medicare Provider Number
380017
Participating Start Date
10/1/2016
Last Recertification Date
9/2/2024
Pharmacy Details
Pharmacy Name
PROCARE PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #2923
3250 HARDEN ST. EXT. SUITE #300
COLUMBIA, SC 29203
Pharmacy Comments
Contract Details
Approval Date
10/3/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Majid Tanas, VP Pharmacy Services
(503) 415-5011
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/3/2021
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