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FRED MEYER STORES
DSH500041 PEACEHEALTH ST. JOHN MEDICAL CENTER
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Covered Entity Details
Entity Name
PEACEHEALTH ST. JOHN MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500041
Entity Address
1615 DELAWARE ST
LONGVIEW, WA 98632
Medicare Provider Number
500041
Participating Start Date
7/1/2004
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
FRED MEYER STORES
Pharmacy Address
3184 OCEAN BEACH HIGHWAY
LONGVIEW, WA 98632
Pharmacy Comments
Contract Details
Approval Date
12/6/2012
Contract Begin Date
12/6/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Thomas Haywood, Regional Chief Financial Officer
(360) 514-3103
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
9/29/2012
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