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CORAM ALTERNATE SITE SERVICES, INC.
DSH380004 PROVIDENCE ST. VINCENT MEDICAL CENTER
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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
CORAM ALTERNATE SITE SERVICES, INC.
Pharmacy Address
DBA CORAM CVS/SPECIALTY INFUSION SERVICE
7358 S W DURHAM ROAD
PORTLAND, OR 97224
Pharmacy Comments
Contract Details
Approval Date
10/12/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Nancy S. Roberts, Chief Operating Officer
(503) 216-4609
Contract Pharmacy Representative
CVS
Maria Michalczyk, Branch Manager
(503) 684-3046
Signed By Date
10/12/2017
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