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CYSTIC FIBROSIS SERVICES, LLC
SCH380001-00 Mid-Columbia Medical Center DBA Adventist Health Columbia Gorge
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Covered Entity Details
Entity Name
Mid-Columbia Medical Center DBA Adventist Health Columbia Gorge
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH380001-00
Entity Address
1700 E 19TH STREET
THE DALLES, OR 97058-3398
Medicare Provider Number
380001
Participating Start Date
9/28/2010
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
6/28/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/12/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
DENNIS KNOX, CEO
(541) 296-7272
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
6/28/2017
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