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MULTICARE MEDICAL CENTER
DSH500079 GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500079
Entity Address
401 15th Avenue SE
PUYALLUP, WA 98372
Medicare Provider Number
500079
Participating Start Date
1/1/2022
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
MULTICARE MEDICAL CENTER
Pharmacy Address
MS: 315-C2-RX
315 MARTIN LUTHER KING JR WAY
DEPT OF PHARMACY SERVICES
TACOMA, WA 98405
Pharmacy Comments
Contract Details
Approval Date
4/14/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Florence Chang, President
(253) 403-7355
Contract Pharmacy Representative
MultiCare Health System
Vafa Aflatooni, Director Pharmacy Supply Chain and 340B
(253) 403-2082
Signed By Date
4/14/2016
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