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ALBERTSONS LLC
DSH380025 LEGACY MOUNT HOOD MEDICAL CENTER
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Covered Entity Details
Entity Name
LEGACY MOUNT HOOD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380025
Entity Address
24800 SE STARK ST
GRESHAM, OR 97030
Medicare Provider Number
380025
Participating Start Date
7/1/2007
Last Recertification Date
9/2/2024
Pharmacy Details
Pharmacy Name
ALBERTSONS LLC
Pharmacy Address
SAFEWAY PHARMACY #536
25691 SE STARK ST
TROUTDALE, OR 97060
Pharmacy Comments
Contract Details
Approval Date
5/3/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/16/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Majid Tanas, VP Pharmacy Services
(503) 415-5011
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
5/3/2023
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