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PROVIDENCE HEALTH & SERVICES - OREGON
DSH380004 PROVIDENCE ST. VINCENT MEDICAL CENTER
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Covered Entity Details
Entity Name
PROVIDENCE ST. VINCENT MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380004
Entity Address
9205 SW BARNES RD
PORTLAND, OR 97225
Medicare Provider Number
380004
Participating Start Date
1/1/2016
Last Recertification Date
8/28/2024
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
10/13/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/18/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Nancy S. Roberts, Chief Operating Officer
(503) 216-4609
Contract Pharmacy Representative
Providence. Health & Services
John Evans, Director, Retail Ops
(503) 215-6296
Signed By Date
10/13/2016
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