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THRIFTY PAYLESS, INC.
DSH500079 GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500079
Entity Address
401 15th Avenue SE
PUYALLUP, WA 98372
Medicare Provider Number
500079
Participating Start Date
1/1/2022
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
THRIFTY PAYLESS, INC.
Pharmacy Address
RITE AID #5271
7041 PACIFIC AVENUE
TACOMA, WA 98408
Pharmacy Comments
Contract Details
Approval Date
11/30/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/30/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Florence Chang, President
(253) 403-7355
Contract Pharmacy Representative
MultiCare Health System
Cindy Wilson, Assistant Vice President - Pharmacy Compliance
(253) 403-2822
Signed By Date
10/25/2021
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