Contract Pharmacy Details

PROCARE PHARMACY, L.L.C.
DSH500003 SKAGIT VALLEY HOSPITAL

Covered Entity Details

Entity Name

SKAGIT VALLEY HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH500003

Entity Address

1415 EAST KINCAID
MOUNT VERNON, WA 98274-4126

Medicare Provider Number

500003

Participating Start Date

7/1/2006

Last Recertification Date

8/21/2024

Pharmacy Details

Pharmacy Name

PROCARE PHARMACY, L.L.C.

Pharmacy Address

DBA CVS/PHARMACY #2819
1309 NW 23RD AVE.
PORTLAND, OR 97210

Pharmacy Comments

Contract Details

Approval Date

4/17/2018

Contract Begin Date

7/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

6/29/2018
Agreement registered in error

Contacts

Covered Entity Signing Official

Paul Ishizuka, CFO
(360) 814-5838

Contract Pharmacy Representative

CVS Health
Christian Reid, 340B Program Director
(401) 770-2118

Signed By Date

4/17/2018

340B Drug Pricing Program Database