Contract Pharmacy Details

QFC PHARMACY #874
FQHC638487A SNOQUALMIE INDIAN TRIBE

Covered Entity Details

Entity Name

SNOQUALMIE INDIAN TRIBE

Subdivision Name

NORTH BEND FAMILY CLINIC

Type

Tribal Contract/Compact with IHS (P.L. 93-638)

340B ID

FQHC638487A

Entity Address

404 MAIN AVENUE S
NORTH BEND, WA 98045

Grant Number

Participating Start Date

7/1/2005

Last Recertification Date

2/23/2017

Entity Termination Date

4/1/2017

Pharmacy Details

Pharmacy Name

QFC PHARMACY #874

Pharmacy Address

1510 145 PLACE SE
BELLEVUE, WA 98007

Pharmacy Comments

Contract Details

Approval Date

3/26/2015

Contract Begin Date

4/1/2015

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2017

Contacts

Covered Entity Signing Official

Rebecca Crocker, Health & Wellness Officer
(425) 888-6551 Ext: 6226

Contract Pharmacy Representative

Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672

Signed By Date

3/26/2015

340B Drug Pricing Program Database