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APOTHECARY AT GOOD SAMARITAN
DSH500150 LEGACY SALMON CREEK HOSPITAL
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Covered Entity Details
Entity Name
LEGACY SALMON CREEK HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500150
Entity Address
2211 NE 139TH ST
VANCOUVER, WA 98686
Medicare Provider Number
500150
Participating Start Date
7/1/2007
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
APOTHECARY AT GOOD SAMARITAN
Pharmacy Address
1040 NW 22ND AVE
STE 100
PORTLAND, OR 97210
Pharmacy Comments
Contract Details
Approval Date
1/14/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Majid Tanas, VP Pharmacy Services
(503) 415-5011
Contract Pharmacy Representative
Legacy Health
Elena Valcarlos, Pharmacy Systems Manager
(503) 413-7764
Signed By Date
1/14/2022
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