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CREDENA HEALTH, LLC
DSH380061 PROVIDENCE PORTLAND MEDICAL CENTER
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Covered Entity Details
Entity Name
PROVIDENCE PORTLAND MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380061
Entity Address
4805 NE GLISAN ST
PORTLAND, OR 97213
Medicare Provider Number
380061
Participating Start Date
7/1/2015
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
CREDENA HEALTH, LLC
Pharmacy Address
6348 NE HALSEY ST
SUITE A
PORTLAND, OR 97213-4720
Pharmacy Comments
Contract Details
Approval Date
7/27/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Paul Gaden, Chief Executive
(503) 215-8603
Contract Pharmacy Representative
Providence
Tammy Pierce, Director of Pharmacy
(503) 962-1700
Signed By Date
7/27/2016
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