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OPTION CARE LEGACY HEALTH, LLC
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
OPTION CARE LEGACY HEALTH, LLC
Pharmacy Address
D/B/A OPTION CARE AT LEGACY HEALTH
16195 S.W. 72ND AVENUE
PORTLAND, OR 97224-7766
Pharmacy Comments
Contract Details
Approval Date
1/13/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/4/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
WALTER LARSON, CFO
(503) 815-2260
Contract Pharmacy Representative
Option Care
Jon Adair, Vice President, Health System Solutions
(847) 830-9996
Signed By Date
1/13/2016
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