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APOTHECARY AT GOOD SAMARITAN
DSH380025 LEGACY MOUNT HOOD MEDICAL CENTER
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Covered Entity Details
Entity Name
LEGACY MOUNT HOOD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380025
Entity Address
24800 SE STARK ST
GRESHAM, OR 97030
Medicare Provider Number
380025
Participating Start Date
7/1/2007
Last Recertification Date
9/2/2024
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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