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EVERGREEN PHARMACEUTICAL LLC
DSH500003 SKAGIT VALLEY HOSPITAL
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Covered Entity Details
Entity Name
SKAGIT VALLEY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500003
Entity Address
1415 EAST KINCAID
MOUNT VERNON, WA 98274-4126
Medicare Provider Number
500003
Participating Start Date
7/1/2006
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
EVERGREEN PHARMACEUTICAL LLC
Pharmacy Address
OMNICARE OF SEATTLE
12674 GATEWAY DR S
TUKWILA, WA 98168-3307
Pharmacy Comments
Contract Details
Approval Date
1/13/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Paul Ishizuka, CFO
(360) 814-5838
Contract Pharmacy Representative
CVS Health
Christian Reid, 340B Program Director
(401) 770-2118
Signed By Date
1/13/2023
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