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FRED MEYER INC
FQHC638552 COHO Benefits of Confederated Tribes of Siletz Indians
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Covered Entity Details
Entity Name
COHO Benefits of Confederated Tribes of Siletz Indians
Subdivision Name
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638552
Entity Address
1777nw 44th street
lincoln city, OR 97367
Grant Number
Participating Start Date
1/1/2019
Last Recertification Date
2/5/2019
Entity Termination Date
1/1/2020
Pharmacy Details
Pharmacy Name
FRED MEYER INC
Pharmacy Address
150 N.E. 20TH ST
NEWPORT, OR 97365
Pharmacy Comments
Contract Details
Approval Date
10/26/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Carmen F Riviello, Benefits Manager
(541) 996-5882
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
10/11/2018
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