Contract Pharmacy Details

WASHINGTON CVS PHARMACY, L.L.C.
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

WASHINGTON CVS PHARMACY, L.L.C.

Pharmacy Address

CVS PHARMACY # 17361
1215 N LANDING WAY
RENTON, WA 98057

Pharmacy Comments

Contract Details

Approval Date

4/15/2022

Contract Begin Date

7/1/2022

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Florence Chang, President
(253) 403-7355

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

4/15/2022

340B Drug Pricing Program Database