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QFC
CAH501323-00 JEFFERSON HEALTHCARE
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Covered Entity Details
Entity Name
JEFFERSON HEALTHCARE
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH501323-00
Entity Address
834 Sheridan St
Port Townsend, WA 98368
Medicare Provider Number
501323
Participating Start Date
1/1/2011
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
QFC
Pharmacy Address
DBA PORT HADLOCK PHARMACY
1890 IRONDALE ROAD
PO BOX 149
PORT HADLOCK, WA 98339
Pharmacy Comments
1/18/2012 updated name (was QFC Pharmacy #495)
Contract Details
Approval Date
10/20/2011
Contract Begin Date
10/15/2011
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mike Glenn, Chief Executive Officer
(360) 385-2200 Ext: 2000
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
10/5/2011
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