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FRED MEYER
SCH380001-00 Mid-Columbia Medical Center DBA Adventist Health Columbia Gorge
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Covered Entity Details
Entity Name
Mid-Columbia Medical Center DBA Adventist Health Columbia Gorge
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH380001-00
Entity Address
1700 E 19TH STREET
THE DALLES, OR 97058-3398
Medicare Provider Number
380001
Participating Start Date
9/28/2010
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
FRED MEYER
Pharmacy Address
1215 W 6TH ST
THE DALLES, OR 97058
Pharmacy Comments
Contract Details
Approval Date
3/14/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DONALD ARBON, V.P. FINANCE/CFO
(541) 296-7524
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
1/21/2013
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