Contract Pharmacy Details

OVERLAKE PHARMACY, LLC
FQHCLA405 Cascade Aids Project

Covered Entity Details

Entity Name

Cascade Aids Project

Subdivision Name

Prism Health

Type

Health Center Program Look-Alike

340B ID

FQHCLA405

Entity Address

2236 SE Belmont St
Portland, OR 97214-2817

Grant Number

LALCS33965

Participating Start Date

4/16/2020

Last Recertification Date

2/24/2025

Pharmacy Details

Pharmacy Name

OVERLAKE PHARMACY, LLC

Pharmacy Address

4124 148TH AVE NE STE JA
REDMOND, WA 98052

Pharmacy Comments

Contract Details

Approval Date

4/8/2020

Contract Begin Date

4/21/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Tyler A. TerMeer, Executive Director
(503) 278-3810

Contract Pharmacy Representative

Overlake Pharmacy LLC
Thao Phan, Pharmacist in Charge
(425) 968-8766

Signed By Date

4/8/2020

340B Drug Pricing Program Database