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WILSON DRUG INCORPORATED
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
WILSON DRUG INCORPORATED
Pharmacy Address
DBA: TILLAMOOK PHARMACY
915 MAIN AVENUE
TILLAMOOK, OR 97141
Pharmacy Comments
Contract Details
Approval Date
4/3/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/18/2018
Ownership change
Contacts
Covered Entity Signing Official
WALTER LARSON, CFO
(503) 815-2260
Contract Pharmacy Representative
David Wilson, Owner
(503) 842-4181
Signed By Date
4/3/2013
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