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MULTICARE HOME INFUSION
DSH500139 CAPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
CAPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500139
Entity Address
3900 CAPITAL MALL DRIVE SW
OLYMPIA, WA 98502
Medicare Provider Number
500139
Participating Start Date
7/1/2022
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
MULTICARE HOME INFUSION
Pharmacy Address
315 MARTIN LUTHER KING JR WAY
PO BOX 5299
TACOMA, WA 98415-0299
Pharmacy Comments
Contract Details
Approval Date
7/13/2022
Contract Begin Date
10/1/2022
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
Renee Percosky, Director Ambulatory Infusion Pharmacy
(253) 403-7222
Signed By Date
7/13/2022
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