Contract Pharmacy Details

SHOPKO PHARMACY #2093
DSH380047 St. Charles Health System, Inc., d/b/a St. Charles Bend

Covered Entity Details

Entity Name

St. Charles Health System, Inc., d/b/a St. Charles Bend

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH380047

Entity Address

2500 NE NEFF ROAD
BEND, OR 97701

Medicare Provider Number

380047

Participating Start Date

7/1/2016

Last Recertification Date

8/12/2024

Pharmacy Details

Pharmacy Name

SHOPKO PHARMACY #2093

Pharmacy Address

60 NE BEND RIVER MALL AVE
BEND, OR 97701

Pharmacy Comments

Contract Details

Approval Date

7/18/2017

Contract Begin Date

10/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

11/28/2018
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Jennifer Rue Welander, Chief Financial Officer
(541) 706-7707

Contract Pharmacy Representative

ShopKo
Lorie Neumann, Contracting & Compliance
(920) 429-4726

Signed By Date

7/18/2017

340B Drug Pricing Program Database