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KELLEY-ROSS PHARMACY
DSH500064 HARBORVIEW MEDICAL CENTER
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Covered Entity Details
Entity Name
HARBORVIEW MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500064
Entity Address
325 9TH AVE.
SEATTLE, WA 98104-2499
Medicare Provider Number
500064
Participating Start Date
12/1/1992
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
KELLEY-ROSS PHARMACY
Pharmacy Address
904 7TH AVE # 103
SEATTLE, WA 98104-1132
Pharmacy Comments
Contract Details
Approval Date
10/4/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
MAUREEN BROOM, Enterprise Finance Officer
(206) 598-5362
Contract Pharmacy Representative
Kelley-Ross
Alen Chen, Pharmacy Manager
(206) 838-4590
Signed By Date
10/4/2017
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