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DIPLOMAT SPECIALTY PHARMACY OF SOUTHERN
CAH381303-00 PROVIDENCE HEALTH DBA PROVIDENCE SEASIDE HOSPITAL
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Covered Entity Details
Entity Name
PROVIDENCE HEALTH DBA PROVIDENCE SEASIDE HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH381303-00
Entity Address
725 S. WAHANNA RD.
SEASIDE, OR 97138-7735
Medicare Provider Number
381303
Participating Start Date
7/1/2011
Last Recertification Date
8/22/2024
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
1/14/2017
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
PAMELA J. Cooper, CHIEF FINANCIAL OFFICER
(503) 717-7296
Contract Pharmacy Representative
Diplomat
Sandra Barbosa, Pharmacy Manager
(602) 366-4692
Signed By Date
1/14/2017
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