Contract Pharmacy Details

THRIFTY PAYLESS, INC.
DSH500079 GOOD SAMARITAN HOSPITAL

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 #6521
22201 MERIDIAN AVENUE E
GRAHAM, WA 98338

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

9/28/2023
Pharmacy closed

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

340B Drug Pricing Program Database