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OVERLAKE PHARMACY, LLC
CH108170 Dirne Health Centers, Inc.
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Covered Entity Details
Entity Name
Dirne Health Centers, Inc.
Subdivision Name
Heritage Health CDA
Type
HRSA-Funded Health Center
340B ID
CH108170
Entity Address
1090 W Park Pl
Coeur D Alene, ID 83814-2785
Grant Number
H80CS02331
Participating Start Date
4/1/2004
Last Recertification Date
3/5/2025
Pharmacy Details
Pharmacy Name
OVERLAKE PHARMACY, LLC
Pharmacy Address
4124 148TH AVE NE STE JA
REDMOND, WA 98052
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/12/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael Baker, CEO
(208) 292-0256
Contract Pharmacy Representative
Overlake Pharmacy LLC
Thao Phan, Pharmacist in Charge
(425) 968-8766
Signed By Date
1/15/2020
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