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CUSTOM PRESCRIPTION SHOPPE
CH101020 Sea Mar Community Health Centers
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Covered Entity Details
Entity Name
Sea Mar Community Health Centers
Subdivision Name
Sea Mar CHC - Administration
Type
HRSA-Funded Health Center
340B ID
CH101020
Entity Address
1040 S. Henderson St.
Seattle, WA 98108
Grant Number
H80CS00445
Participating Start Date
12/1/1992
Last Recertification Date
2/17/2025
Pharmacy Details
Pharmacy Name
CUSTOM PRESCRIPTION SHOPPE
Pharmacy Address
5917 PORTAL WAY
FERNDALE, WA 98248
Pharmacy Comments
Contract Details
Approval Date
1/14/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/15/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mary Bartolo, VP, Deputy Director
(206) 763-5277
Contract Pharmacy Representative
Western Pharmacy Group LLC
KEVIN FARIS, CEO
(360) 685-4263
Signed By Date
1/14/2019
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