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OHSU GABRIEL PARK PHARMACY
DSH380051 Salem Health
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Covered Entity Details
Entity Name
Salem Health
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380051
Entity Address
890 Oak Street SE
Salem, OR 97301
Medicare Provider Number
380051
Participating Start Date
7/1/2012
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
OHSU GABRIEL PARK PHARMACY
Pharmacy Address
4411 SW VERMONT ST
VERMONT HILLS PLAZA
PORTLAND, OR 97219-1020
Pharmacy Comments
Contract Details
Approval Date
10/25/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James Parr, Chief Financial Officer
(503) 814-2841
Contract Pharmacy Representative
OHSU
Jennifer Zanon, Director Pharmacy Services; Regulatory Compliance
(503) 418-1286
Signed By Date
10/25/2016
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