Covered Entity Details

FQHC638492 COW CREEK BAND OF UMPQUA TRIBE OF INDIANS (Active) - information as of 6/9/2025 11:04:53 PM

Main Details

Name

COW CREEK BAND OF UMPQUA TRIBE OF INDIANS

Subdivision Name

COW CREEK HEALTH AND WELLNESS CENTER

Type

Tribal Contract/Compact with IHS (P.L. 93-638)

340B ID

FQHC638492

Additional Details

Current Program Status

Active

Registration Date

4/4/2019

Participating Start Date

7/1/2019

Participating Approval Date

5/1/2019

Last Recertification Date

2/26/2025

Contacts

Authorizing Official

Cow Creek Band of Umpqua Tribe of Indians
Allyson Kristine Nicolas, Health Operations Officer
(541) 900-9215

Primary Contact

Cow Creek Health & Wellness Center
Tamara Ann Robinson, Clinic Operations Coordinator
(541) 691-2433

Addresses

Street Address

2589 NW Edenbower Blvd
ROSEBURG, OR 97471-6220

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
History

Comments

Comment	Last Updated On
Participating from effective date (10/1/2009), until terminated effective date (4/1/2019), reinstatement effective date (07/01/2019)	05/01/2019

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
OR	500745176	1134567993

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	FRED MEYER STORES INC	FRED MEYER PHARMACY #281	929 NW GARDEN VALLEY BLVD	ROSEBURG	OR	97471	05/01/2019	07/01/2019		07/01/2019
Contract Detail	GORDON'S PHARMACY AND GIFTS, LLC	314 S MAIN ST		CANYONVILLE	OR	97417-9645	05/01/2019	07/01/2019		07/01/2019
Contract Detail	HEALTHY OPTIONS INC	DBA POSTAL PRESCRIPTION SVCS	3500 SE 26TH AVE PO BOX 2718	PORTLAND	OR	97202	05/01/2019	07/01/2019		07/01/2019
Contract Detail	HOMETOWN DRUGS OF ROSEBURG INC	1813 W HARVARD STREET	SUITE 210	ROSEBURG	OR	97471	07/01/2013	10/01/2013	04/01/2019	04/01/2019
Contract Detail	HOMETOWN DRUGS OF ROSEBURG INC	1813 W HARVARD STREET	SUITE 210	ROSEBURG	OR	97471	05/01/2019	07/01/2019		07/01/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #4904	821 SOUTH MAIN STREET	MYRTLE CREEK	OR	97457	07/12/2019	10/01/2019		10/01/2019
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/16/2020	07/01/2020		07/01/2020
Contract Detail	WAL-MART PHARMACY 10-2477	2125 NW STEWART PKWY		ROSEBURG	OR	97471	04/16/2020	07/01/2020		07/01/2020
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/16/2020	07/01/2020		07/01/2020

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/6/2024 12:22:52 AM	2/26/2025 2:13:12 AM	2/26/2025 2:13 AM
Contacts	Authorizing Official	Update	Group Change Request	Bae, Jacqueline j Health Operations Officer Tribal 2136632538	Nicolas, Allyson Kristine Health Operations Officer Cow Creek Band of Umpqua Tribe of Indians 5419009215	2/19/2025 7:51 AM
Contacts	Primary Contact	Update	PC Change Request	Yates, Chanda Clinic Director Cow Creek Health & Wellness Center 5415300342	Robinson, Tamara Ann Clinic Operations Coordinator Cow Creek Health & Wellness Center 5416912433	2/8/2024 2:23 PM
Details	Last Recertification Date	Update	Recertification	1/31/2023 12:41:31 AM	2/6/2024 12:22:52 AM	2/6/2024 12:22 AM
Contacts	Authorizing Official	Update	AO Change Request	Stanphill, Sharon Arlene Health Operations Officer Cow Creek Band of Umpqua Tribe of Indians 5416728533-5517	Bae, Jacqueline j Health Operations Officer Tribal 2136632538	2/5/2024 6:59 AM
Details	Last Recertification Date	Update	Recertification	2/8/2022 12:07:26 AM	1/31/2023 12:41:31 AM	1/31/2023 12:41 AM
Contacts	Authorizing Official	Update	Change Request	Stanphill, Sharon Health Operations Officer Cow Creek Band of Umpqua Tribe of Indians 5416728533-5517	Stanphill, Sharon Arlene Health Operations Officer Cow Creek Band of Umpqua Tribe of Indians 5416728533-5517	1/20/2023 9:48 AM
Details	Last Recertification Date	Update	Recertification	2/19/2021 8:17:23 AM	2/8/2022 12:07:26 AM	2/8/2022 12:07 AM
Addresses	Main Address	Update	Change Request	2371 NE STEPHENS STREET SUITE 200 ROSEBURG, OR 97470	2589 NW Edenbower Blvd ROSEBURG, OR 97471-6220	12/22/2021 8:04 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	500745176 (OR)		2/19/2021 8:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/19/2021 8:17 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		500745176	2/19/2021 8:17 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OR	2/19/2021 8:17 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1063502714 ( )		2/19/2021 8:17 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1134567993 ( )		2/19/2021 8:17 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1134567993	2/19/2021 8:17 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	2/19/2021 8:17 AM
Contacts	Primary Contact	Update	Recertification	Patterson, Sheree Dawn A/R Clerk Cow Creek Health & Wellness Center 5414925215	Yates, Chanda Clinic Director Cow Creek Health & Wellness Center 5415300342	2/19/2021 8:17 AM
Details	Last Recertification Date	Update	Recertification	1/28/2020 12:16:21 PM	2/19/2021 8:17:23 AM	2/19/2021 8:17 AM
Contacts	Authorizing Official	Update	AO Change Request	Eberhardt, Dennis Edmond Clinic Director Cow Creek Health & Wellness 5416775510	Stanphill, Sharon Health Operations Officer Cow Creek Band of Umpqua Tribe of Indians 5416728533-5517	2/11/2021 8:53 AM
Details	Last Recertification Date	Update	Recertification		1/28/2020 12:16:21 PM	1/28/2020 12:16 PM
Details	State	Update		Approved	Active	7/1/2019 12:05 AM
Addresses	Main Address	Insert	Reinstatement		2371 NE STEPHENS STREET SUITE 200 ROSEBURG, OR 97470	5/1/2019 1:47 PM
Contacts	Authorizing Official	Update	Reinstatement	Stanphill, Sharon Health Operations Officer Cow Creek Band of Umpqua Tribe of Indians 5416728533-5517	Eberhardt, Dennis Edmond Clinic Director Cow Creek Health & Wellness 5416775510	5/1/2019 1:47 PM
Contacts	Signed By	Insert	Reinstatement		Eberhardt, Dennis Edmond Clinic Director Cow Creek Health & Wellness 5416775510	5/1/2019 1:47 PM
Contacts	Primary Contact	Update	Reinstatement	Stevenson, Mary Health Business Operations Administration Cow Creek Health & Wellness Center 5416728533-5200	Patterson, Sheree Dawn A/R Clerk Cow Creek Health & Wellness Center 5414925215	5/1/2019 1:47 PM
Dates	Participating Approval Date	Update	Reinstatement		5/1/2019 1:47:28 PM	5/1/2019 1:47 PM
Details	State	Update	Reinstatement	Pending	Approved	5/1/2019 1:47 PM
Dates	Signed By Date	Update	Reinstatement	7/2/2009 12:00:00 AM	4/4/2019 2:19:15 PM	5/1/2019 1:47 PM
Dates	Start Date	Update	Reinstatement		7/1/2019 12:00:00 AM	5/1/2019 1:47 PM
Details	Comments Public	Insert	Reinstatement		Participating from effective date (10/1/2009), until terminated effective date (4/1/2019), reinstatement effective date (07/01/2019)	5/1/2019 1:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	4/4/2019 6:19 PM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		500745176	4/4/2019 6:19 PM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		OR	4/4/2019 6:19 PM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1063502714	4/4/2019 6:19 PM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1134567993	4/4/2019 6:19 PM
Details	Last Recertification Date	Update	Reinstatement	2/26/2018 3:11:40 PM		4/4/2019 2:19 PM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	4/1/2019 12:00:00 AM		4/4/2019 2:19 PM
Dates	Participating Approval Date	Update	Reinstatement	7/24/2009 12:00:00 AM		4/4/2019 2:19 PM
Details	State	Update	Reinstatement	Terminated	Pending	4/4/2019 2:19 PM
Dates	Registration Date	Update	Reinstatement	7/24/2009 12:00:00 AM	4/4/2019 2:19:13 PM	4/4/2019 2:19 PM
Dates	Start Date	Update	Reinstatement	10/1/2009 12:00:00 AM		4/4/2019 2:19 PM
Terminations	Termination Date	Update	Reinstatement	4/1/2019 12:00:00 AM		4/4/2019 2:19 PM
Terminations	Termination Effective Date	Update	Reinstatement	4/1/2019 12:00:00 AM		4/4/2019 2:19 PM
Terminations	Termination Reason	Update	Reinstatement	Failure to recertify		4/4/2019 2:19 PM
Details	State	Update		To Be Terminated	Terminated	4/1/2019 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		4/1/2019 12:00:00 AM	2/28/2019 9:02 AM
Details	State	Update	Recertification	Active	To Be Terminated	2/28/2019 9:02 AM
Terminations	Termination Date	Update	Recertification		4/1/2019 12:00:00 AM	2/28/2019 9:02 AM
Terminations	Termination Effective Date	Update	Recertification		4/1/2019 12:00:00 AM	2/28/2019 9:02 AM
Terminations	Termination Reason	Update	Recertification		Failure to recertify	2/28/2019 9:02 AM
Details	Last Recertification Date	Update	Recertification	2/16/2017 12:00:00 AM	2/26/2018 3:11:40 PM	2/26/2018 3:11 PM
Contacts	Authorizing Official	Update	Profile Change Request	Stanphill, Sharon Health Director Cow Creek Band of Umpqua Tribe of Indians 5416728533-5517	Stanphill, Sharon Health Operations Officer Cow Creek Band of Umpqua Tribe of Indians 5416728533-5517	2/1/2018 12:09 PM
Contacts	Authorizing Official	Update		Stanphill, Sharon Health Director 5416728533-5517	Stanphill, Sharon Health Director Cow Creek Band of Umpqua Tribe of Indians 5416728533-5517	2/1/2018 12:06 PM
Contacts	Primary Contact	Update	Profile Change Request	Stevenson, Mary Assistant Health Director Cow Creek Health & Wellness Center 5416728533-5200	Stevenson, Mary Health Business Operations Administration Cow Creek Health & Wellness Center 5416728533-5200	1/24/2018 1:38 PM
Contacts	Primary Contact	Update		Stevenson, Mary Assistant Health Director 5416728533-5200	Stevenson, Mary Assistant Health Director Cow Creek Health & Wellness Center 5416728533-5200	1/24/2018 1:33 PM
Contacts	Primary Contact	Insert			Stevenson, Mary Assistant Health Director 5416728533-5200	2/16/2017 11:40 AM
Contacts	Authorizing Official	Update		Stanpill, Sharon Health Director 5416728533	Stanphill, Sharon Health Director 5416728533-5517	2/16/2017 11:40 AM
Addresses	Main Address	Insert			2371 NE STEPHENS STREET SUITE 200 ROSEBURG, OR 97470	2/16/2017 11:38 AM
Details	Last Recertification Date	Update		3/1/2016 12:00:00 AM	2/16/2017 12:00:00 AM	2/16/2017 11:38 AM
Details	Last Recertification Date	Update		1/29/2015 12:00:00 AM	3/1/2016 12:00:00 AM	3/1/2016 11:51 AM
Details	Last Recertification Date	Update		2/10/2014 12:00:00 AM	1/29/2015 12:00:00 AM	1/29/2015 3:42 PM
Details	Last Recertification Date	Update		4/1/2013 12:00:00 AM	2/10/2014 12:00:00 AM	2/10/2014 11:54 AM
Details	Last Recertification Date	Update			4/1/2013 12:00:00 AM	3/12/2013 8:41 AM
Contacts	Authorizing Official	Insert			Stanpill, Sharon Health Director 5416728533	7/6/2012 9:53 AM
Details	Last Recertification Date	Insert				7/24/2009 4:08 PM
Details	Grant Number	Insert				7/24/2009 4:08 PM
Details	340B ID	Insert			FQHC638492	7/24/2009 4:08 PM
Details	Is Authorizing Official EHB Data	Insert				7/24/2009 4:08 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/24/2009 4:08 PM
Details	Medicare Provider Number	Insert				7/24/2009 4:08 PM
Details	Entity Name	Insert			COW CREEK BAND OF UMPQUA TRIBE OF INDIANS	7/24/2009 4:08 PM
Details	Program Code	Insert			FQHC638	7/24/2009 4:08 PM
Details	Entity Subname	Insert			COW CREEK HEALTH AND WELLNESS CENTER	7/24/2009 4:08 PM
Dates	Participating Approval Date	Insert			7/24/2009 12:00:00 AM	7/24/2009 4:08 PM
Details	State	Insert			Active	7/24/2009 4:08 PM
Dates	Registration Date	Insert			7/24/2009 12:00:00 AM	7/24/2009 4:08 PM
Dates	Signed By Date	Insert			7/2/2009 12:00:00 AM	7/24/2009 4:08 PM
Dates	Start Date	Insert			10/1/2009 12:00:00 AM	7/24/2009 4:08 PM
Terminations	Termination Comments	Insert				7/24/2009 4:08 PM
Terminations	Termination Date	Insert				7/24/2009 4:08 PM
Terminations	Termination Effective Date	Insert				7/24/2009 4:08 PM
Terminations	Termination Reason	Insert				7/24/2009 4:08 PM

340B Drug Pricing Program Database

Comments

Medicaid Billing

Shipping Addresses

Contract Pharmacies

History