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FRED MEYER STORES
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
FRED MEYER STORES
Pharmacy Address
ATTN: PHARMACY
920 SOUTH BURLINGTON BLVD
BURLINGTON, WA 98233
Pharmacy Comments
Contract Details
Approval Date
3/15/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tom Litaker, CFO
(360) 428-2166
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
1/28/2013
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