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WAL-MART PHARMACY 10-5440
DSH380060 Portland Adventist Medical Center dba Adventist Health Portland
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Covered Entity Details
Entity Name
Portland Adventist Medical Center dba Adventist Health Portland
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380060
Entity Address
10123 SE Market Street
Portland, OR 97216
Medicare Provider Number
380060
Participating Start Date
10/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5440
Pharmacy Address
10000 SOUTHEAST 82ND AVENUE
HAPPY VALLEY, OR 97086
Pharmacy Comments
Contract Details
Approval Date
10/9/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jason Panasuk, Finance Officer
(503) 251-6121
Contract Pharmacy Representative
Adventist Health Portland
Kirsten Wallskog Sedgwick, Director of Pharmacy
(503) 251-6141
Signed By Date
10/9/2023
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