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SAMARITAN LEBANON COMMUNITY PHARMACY
DSH380014 GOOD SAMARITAN HOSPITAL CORVALLIS
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Covered Entity Details
Entity Name
GOOD SAMARITAN HOSPITAL CORVALLIS
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380014
Entity Address
3600 NW SAMARITAN DRIVE
CORVALLIS, OR 97330
Medicare Provider Number
380014
Participating Start Date
7/1/2017
Last Recertification Date
11/18/2017
Entity Termination Date
7/1/2018
Pharmacy Details
Pharmacy Name
SAMARITAN LEBANON COMMUNITY PHARMACY
Pharmacy Address
675 N 5TH ST
LEBANON, OR 97355-2875
Pharmacy Comments
Contract Details
Approval Date
4/18/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Daniel Smith, VP Finance/CFO
(541) 768-5390
Contract Pharmacy Representative
Good Samaritan Regional Medical Center
Penny Reher, Chief Pharmacy Officer
(541) 768-6177
Signed By Date
4/18/2017
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