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OVERLAKE PHARMACY, LLC
CH050990 HEALTHSOURCE OF OHIO, INC.
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Covered Entity Details
Entity Name
HEALTHSOURCE OF OHIO, INC.
Subdivision Name
HEALTHSOURCE OF OHIO, INC.
Type
HRSA-Funded Health Center
340B ID
CH050990
Entity Address
424 WARDS CORNER STE 200
LOVELAND, OH 45140-6966
Grant Number
H80CS00201
Participating Start Date
10/1/1998
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
OVERLAKE PHARMACY, LLC
Pharmacy Address
4124 148TH AVE NE STE JA
REDMOND, WA 98052
Pharmacy Comments
Contract Details
Approval Date
1/18/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/25/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
KIM PATTON, CEO
(513) 576-7700
Contract Pharmacy Representative
Overlake Pharmacy LLC
Thao Phan, Pharmacist in Charge
(425) 968-8766
Signed By Date
1/18/2022
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