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FRED MEYER 663
CAH381317-00 NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH381317-00
Entity Address
1000 3RD STREET
TILLAMOOK, OR 97141
Medicare Provider Number
381317
Participating Start Date
9/30/2010
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
FRED MEYER 663
Pharmacy Address
16625 362ND AVENUE
SANDY, OR 97055
Pharmacy Comments
Contract Details
Approval Date
1/11/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
KATHY SAXON, CNO
(503) 815-2260
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
1/11/2021
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