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CAH381317-09 NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER (Terminated)
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Main Details
Name
NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER
Subdivision Name
NORTHWEST MEDICAL FOUNDATION OF TIL - Medical Office - Banks
Type
Critical Access Hospital
Rural
Yes
340B ID
CAH381317-09
Medicare Provider Number
381317
Outpatient Facility Provider Number
388546
Additional Details
Current Program Status
Terminated
Registration Date
10/15/2020
Participating Start Date
1/1/2021
Participating Approval Date
10/19/2020
Last Recertification Date
Termination Date
Termination Reason
10/1/2021
Business decision by the Covered Entity
Contacts
Authorizing Official
Tillamook Regional Medical Center
KATHY SAXON, CNO
(503) 815-2260
Primary Contact
Tillamook Regional Medical Center
KYLE CONNAUGHTON, PHARMACY DIRECTOR
(503) 815-2260
Addresses
Street Address
12350 NW MAIN ST
STE 112
BANKS, OR 97106-9045
Billing Address
Adventist Health Medical Office - Banks
PO Box 458
Tillamook, OR 97141
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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