Contract Pharmacy Details

KITSAP PHARMACY AT THE
FQHC638396 PORT GAMBLE S'KLALLAM TRIBE

Covered Entity Details

Entity Name

PORT GAMBLE S'KLALLAM TRIBE

Subdivision Name

Type

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

340B ID

FQHC638396

Entity Address

32020 LITTLE BOSTON ROAD NE - ADMIN ADDRESS
32020 LITTLE BOSTON ROAD NE - CLINIC ADDRESS
KINGSTON, WA 98346

Grant Number

Participating Start Date

1/1/2001

Last Recertification Date

2/18/2025

Pharmacy Details

Pharmacy Name

KITSAP PHARMACY AT THE

Pharmacy Address

20148 10TH AVE NE
CENTRAL MARKET
POULSBO, WA 98370-7372

Pharmacy Comments

Contract Details

Approval Date

1/1/2002

Contract Begin Date

1/1/2002

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/24/2025
Pharmacy closed

Contacts

Covered Entity Signing Official

Contract Pharmacy Representative

Signed By Date

340B Drug Pricing Program Database