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FRED MEYER STORES INC.
DSH500150 LEGACY SALMON CREEK HOSPITAL
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Covered Entity Details
Entity Name
LEGACY SALMON CREEK HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500150
Entity Address
2211 NE 139TH ST
VANCOUVER, WA 98686
Medicare Provider Number
500150
Participating Start Date
7/1/2007
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
FRED MEYER STORES INC.
Pharmacy Address
FRED MEYER PHARMACY #140
7700 HIGHWAY 99
VANCOUVER, WA 98665
Pharmacy Comments
Contract Details
Approval Date
4/4/2012
Contract Begin Date
7/26/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/25/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David E. Eager, Sr. VP and CFO, Legacy Health
(503) 415-5730
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
2/28/2012
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