Contract Pharmacy Details

THRIFTY PAYLESS, INC.
DSH380014 GOOD SAMARITAN HOSPITAL CORVALLIS

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

THRIFTY PAYLESS, INC.

Pharmacy Address

RITE AID #5369
30 EAST OAK STREET
LEBANON, OR 97355

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

Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968

Signed By Date

4/18/2017

340B Drug Pricing Program Database