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FRED MEYER STORES #215
PED503301-00 Mary Bridge Children's Hospital and Health Center
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Covered Entity Details
Entity Name
Mary Bridge Children's Hospital and Health Center
Subdivision Name
Type
Children's Hospital
340B ID
PED503301-00
Entity Address
317 Martin Luther King Jr Way
Tacoma, WA 98405-4234
Medicare Provider Number
503301
Participating Start Date
10/1/2011
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
FRED MEYER STORES #215
Pharmacy Address
25250 PACIFIC HWY SOUTH
KENT, WA 98032
Pharmacy Comments
Contract Details
Approval Date
4/13/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/30/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Timothy Wayne Lynch, Sr. VP, Chief Administrative Officer
(253) 403-2824
Contract Pharmacy Representative
Kroger Health
Eva Brumfield, Strategic Program Director
(651) 357-2109
Signed By Date
4/13/2023
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