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FRED MEYER STORES
DSH500050 PeaceHealth Southwest Medical Center
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Covered Entity Details
Entity Name
PeaceHealth Southwest Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500050
Entity Address
400 NE Mother Joseph Place
VANCOUVER, WA 98664
Medicare Provider Number
500050
Participating Start Date
4/1/2005
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
FRED MEYER STORES
Pharmacy Address
PHARMACY DEPARTMENT
7411 NE 117TH AVENUE
VANCOUVER, WA 98662
Pharmacy Comments
Contract Details
Approval Date
12/3/2012
Contract Begin Date
12/3/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/28/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Joe Ness, VP of Ancillary and Support Services
(360) 514-2275
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
9/29/2012
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