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MULTICARE GOOD SAM OUTPATIENT PHARMACY
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 GOOD SAM OUTPATIENT PHARMACY
Pharmacy Address
401 15TH AVE SE
MS: 401-D1-ORX
PUYALLUP, WA 98372
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
7/1/2016
Agreement registered in error
Contacts
Covered Entity Signing Official
Florence Chang, President
(253) 403-7355
Contract Pharmacy Representative
Tarak Patel, Pharmacy Supervisor
(253) 403-2953
Signed By Date
4/14/2016
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