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FRED MEYER
CAH381317-01 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
TILLAMOOK MEDICAL GROUP
Type
Critical Access Hospital
340B ID
CAH381317-01
Entity Address
1100 THIRD STREET
TILLAMOOK, OR 97141
Medicare Provider Number
381317
Outpatient Facility Provider Number
388504
Participating Start Date
1/1/2011
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
FRED MEYER
Pharmacy Address
2500 NORTH MAIN STREET
TILLAMOOK, OR 97141
Pharmacy Comments
Contract Details
Approval Date
12/6/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
WALTER LARSON, CFO
(503) 815-2260
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
10/12/2012
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