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CREDENA HEALTH, LLC
DSH500002 PROV ST MARY MEDICAL CENTER
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Covered Entity Details
Entity Name
PROV ST MARY MEDICAL CENTER
Subdivision Name
Providence St. Mary Medical Center
Type
Disproportionate Share Hospital
340B ID
DSH500002
Entity Address
401 W POPLAR ST.
WALLA WALLA, WA 99362-2846
Medicare Provider Number
500002
Participating Start Date
10/1/2022
Last Recertification Date
8/30/2023
Entity Termination Date
7/1/2024
Pharmacy Details
Pharmacy Name
CREDENA HEALTH, LLC
Pharmacy Address
6348 NE HALSEY ST
SUITE A
PORTLAND, OR 97213-4720
Pharmacy Comments
Contract Details
Approval Date
9/21/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/14/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Susan Blackburn, CHIEF EXECUTIVE
(509) 897-2290
Contract Pharmacy Representative
Austin Ewing, Specialty Pharmacy Supervisor
(503) 962-1700
Signed By Date
9/21/2016
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