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FRED MEYER INC
DSH380007 LEGACY EMANUEL HOSPITAL & HEALTH CENTER
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Covered Entity Details
Entity Name
LEGACY EMANUEL HOSPITAL & HEALTH CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380007
Entity Address
2801 N GANTENBEIN AVE
PORTLAND, OR 97227
Medicare Provider Number
380007
Participating Start Date
7/1/2007
Last Recertification Date
9/2/2024
Pharmacy Details
Pharmacy Name
FRED MEYER INC
Pharmacy Address
ATTN: PHARMACY
3030 NE WEIDLER
PORTLAND, OR 97232
Pharmacy Comments
Contract Details
Approval Date
7/26/2012
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
7/20/2012
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