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PROVIDENCE HEALTH & SERVICES - OREGON
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
PROVIDENCE HEALTH & SERVICES - OREGON
Pharmacy Address
PROVIDENCE TANASBOURNE PHARMACY
10670 NE CORNELL RD STE 102
HILLSBORO, OR 97124-9221
Pharmacy Comments
Contract Details
Approval Date
1/4/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Paul Gaden, Chief Executive
(503) 215-8603
Contract Pharmacy Representative
Providence. Health & Services
John Evans, Director, Retail Ops
(503) 215-6296
Signed By Date
1/4/2017
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