Contract Pharmacy Details

WALGREEN CO.
DSH380004 PROVIDENCE ST. VINCENT MEDICAL CENTER

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

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS # 03890
940 SE CESAR E CHAVEZ BLVD
PORTLAND, OR 97214

Pharmacy Comments

Contract Details

Approval Date

1/11/2017

Contract Begin Date

4/1/2017

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Nancy S. Roberts, Chief Operating Officer
(503) 216-4609

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

1/11/2017

340B Drug Pricing Program Database