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DIPLOMAT SPECIALTY PHARMACY OF SOUTHERN
CAH381318-00 PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH381318-00
Entity Address
810 12th Street
HOOD RIVER, OR 97031-1587
Medicare Provider Number
381318
Participating Start Date
4/1/2011
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
DIPLOMAT SPECIALTY PHARMACY OF SOUTHERN
Pharmacy Address
DIPLOMAT SPECIALTY PHARMACY
1809 EXCISE AVENUE
SUITE 204-208
ONTARIO, CA 91761
Pharmacy Comments
Contract Details
Approval Date
1/15/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/11/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Jeanie Vieira, Chief Operating Officer/Chief Nursing Officer
(541) 387-6452
Contract Pharmacy Representative
Diplomat
Sandra Barbosa, Pharmacy Manager
(602) 366-4692
Signed By Date
1/15/2017
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