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OVERLAKE PHARMACY, LLC
CH080730 METRO COMMUNITY PROVIDER NETWORK, INC.
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Covered Entity Details
Entity Name
METRO COMMUNITY PROVIDER NETWORK, INC.
Subdivision Name
STRIDE CHC- Peoria
Type
HRSA-Funded Health Center
340B ID
CH080730
Entity Address
3292 Peoria St
Aurora, CO 80010
Grant Number
H80CS00217
Participating Start Date
12/1/1992
Last Recertification Date
2/21/2025
Pharmacy Details
Pharmacy Name
OVERLAKE PHARMACY, LLC
Pharmacy Address
4124 148TH AVE NE STE JA
REDMOND, WA 98052
Pharmacy Comments
Contract Details
Approval Date
1/14/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/16/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ben Wiederholt, CEO
(303) 761-1977 Ext: 1103
Contract Pharmacy Representative
Overlake Pharmacy LLC
Thao Phan, Pharmacist in Charge
(425) 968-8766
Signed By Date
1/14/2020
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