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KMART PHARMACY #7580
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
KMART PHARMACY #7580
Pharmacy Address
2757 NW STEWART PARKWAY
ROSEBURG, OR 97471
Pharmacy Comments
Contract Details
Approval Date
1/13/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/20/2017
Pharmacy closed
Contacts
Covered Entity Signing Official
KC Bolton, CEO
(541) 672-9596 Ext: 103
Contract Pharmacy Representative
Kmart
Jennifer Speares, Director Administration/Compliance
(904) 783-5183
Signed By Date
1/13/2017
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