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OTHELLO STATION PHARMACY
DSH500064 HARBORVIEW MEDICAL CENTER
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Covered Entity Details
Entity Name
HARBORVIEW MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500064
Entity Address
325 9TH AVE.
SEATTLE, WA 98104-2499
Medicare Provider Number
500064
Participating Start Date
12/1/1992
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
OTHELLO STATION PHARMACY
Pharmacy Address
SALAAM HEALTH PLLC
4219 S OTHELLO ST # 105F
SEATTLE, WA 98118-3892
Pharmacy Comments
Contract Details
Approval Date
1/17/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
MAUREEN BROOM, Enterprise Finance Officer
(206) 598-5362
Contract Pharmacy Representative
Othello Station Pharmacy
Ahmed Ali, OWNER
(206) 620-2400
Signed By Date
1/17/2023
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