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TIN RX #806
FQHC638610 Confederated Tribes of Coos, Lower Umpqua and Siuslaw Indians
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Covered Entity Details
Entity Name
Confederated Tribes of Coos, Lower Umpqua and Siuslaw Indians
Subdivision Name
Three Rivers Health Center
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638610
Entity Address
150 S Wall St
Coos Bay, OR 97420
Grant Number
Participating Start Date
1/1/2024
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
TIN RX #806
Pharmacy Address
3005 E. RENNER RD.
STE. 120
RICHARDSON, TX 75082
Pharmacy Comments
Contract Details
Approval Date
1/16/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Agreement registered in error
Contacts
Covered Entity Signing Official
Lee Ann Wander, CEO
(541) 888-7527
Contract Pharmacy Representative
TIN RX/Castro
Patricia J Nachman, COO
(954) 298-7882
Signed By Date
1/16/2024
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