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WAL-MART PHARMACY 10-2477
FQHC638492 COW CREEK BAND OF UMPQUA TRIBE OF INDIANS
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Covered Entity Details
Entity Name
COW CREEK BAND OF UMPQUA TRIBE OF INDIANS
Subdivision Name
COW CREEK HEALTH AND WELLNESS CENTER
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638492
Entity Address
2589 NW Edenbower Blvd
ROSEBURG, OR 97471-6220
Grant Number
Participating Start Date
7/1/2019
Last Recertification Date
2/26/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2477
Pharmacy Address
2125 NW STEWART PKWY
ROSEBURG, OR 97471
Pharmacy Comments
Contract Details
Approval Date
4/16/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Dennis Edmond Eberhardt, Clinic Director
(541) 677-5510
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/16/2020
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