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FRED MEYER STORES
DSH500008 UNIVERSITY OF WASHINGTON MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF WASHINGTON MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500008
Entity Address
1959 NE PACIFIC ST.,
SEATTLE, WA 98195
Medicare Provider Number
500008
Participating Start Date
12/1/1992
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
FRED MEYER STORES
Pharmacy Address
4615 196TH ST SW SUITE 175
LYNNWOOD, WA 98036
Pharmacy Comments
Contract Details
Approval Date
10/14/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/4/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
PAUL S. ISHIZUKA, ASSOC. EXEC. DIR & CFO
(206) 598-6305
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
10/14/2013
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