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DIPLOMAT SPECIALTY PHARMACY
DSH380038 PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER
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Covered Entity Details
Entity Name
PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380038
Entity Address
1500 DIVISION STREET
OREGON CITY, OR 97045
Medicare Provider Number
380038
Participating Start Date
7/1/2015
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
DIPLOMAT SPECIALTY PHARMACY
Pharmacy Address
4100 S SAGINAW ST
STE D
FLINT, MI 48507-2683
Pharmacy Comments
04/09/2012 update address and name (added suite)
Contract Details
Approval Date
4/6/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Russell P. Reinhard, Chief Executive
(503) 657-6915
Contract Pharmacy Representative
Diplomat Specialty Pharmacy
Greg Jonas, Associate Director Pharmacy
(810) 768-9458
Signed By Date
4/6/2018
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