Contract Pharmacy Details

HAGGEN
DSH500003 SKAGIT VALLEY HOSPITAL

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

HAGGEN

Pharmacy Address

DBA: HAGGEN FOOD & PHARM. #15
757 HAGGEN DRIVE
BURLINGTON, WA 98233

Pharmacy Comments

Contract Details

Approval Date

4/11/2012

Contract Begin Date

4/11/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

8/3/2016
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

THOMAS LITAKER, CFO
(360) 445-8505

Contract Pharmacy Representative

Ron Stevens, CFO
(360) 733-8720

Signed By Date

3/1/2012

340B Drug Pricing Program Database