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WAL-MART PHARMACY 10-1925
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
WAL-MART PHARMACY 10-1925
Pharmacy Address
160 NW 25TH STREET
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
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/11/2018
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