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CORAM ALTERNATE SITE SERVICES, INC.
DSH380017 LEGACY GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
LEGACY GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380017
Entity Address
1015 NW 22ND AVENUE
PORTLAND, OR 97210
Medicare Provider Number
380017
Participating Start Date
10/1/2016
Last Recertification Date
9/2/2024
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
Contract Termination Date
Termination Reason
1/24/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Everett W. Newcomb III, Sr Vice President and COO
(503) 415-5252
Contract Pharmacy Representative
CVS
Maria Michalczyk, Branch Manager
(503) 684-3046
Signed By Date
10/12/2017
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