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CREEKSIDE PHARMACY
CAH501305-00 Lincoln County Public Hospital District No. 3
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Covered Entity Details
Entity Name
Lincoln County Public Hospital District No. 3
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH501305-00
Entity Address
10 Nicholls St
Davenport, WA 99122
Medicare Provider Number
501305
Participating Start Date
7/1/2012
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
CREEKSIDE PHARMACY
Pharmacy Address
639 MORGAN ST
BOX 760
DAVENPORT, WA 99122-5015
Pharmacy Comments
Contract Details
Approval Date
1/15/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/1/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Tim O'Connell, CFO
(509) 725-2979 Ext: 1157
Contract Pharmacy Representative
Creekside Rx
Lanae Wiater, Owner
(509) 725-0935
Signed By Date
1/15/2021
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