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J & I BLACK
CH103100 UMPQUA COMMUNITY HEALTH CENTER, INC., dba Aviva Health
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Covered Entity Details
Entity Name
UMPQUA COMMUNITY HEALTH CENTER, INC., dba Aviva Health
Subdivision Name
Umpqua Community Health Center
Type
HRSA-Funded Health Center
340B ID
CH103100
Entity Address
150 NE Kenneth Ford Drive
Roseburg, OR 97470
Grant Number
H80CS00567
Participating Start Date
10/1/2003
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
J & I BLACK
Pharmacy Address
DBA SUTHERLIN DRUG
113 EAST CENTRAL AVENUE
SUTHERLIN, OR 97479
Pharmacy Comments
Contract Details
Approval Date
1/22/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/23/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Christi Parazoo, Interim CEO
(541) 672-9596 Ext: 102
Contract Pharmacy Representative
Ian Black, Owner / RPh
(541) 459-2712
Signed By Date
1/22/2015
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