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PEACEHEALTH RIVERBEND OUTPATIENT PHARMAC
CAH021311-00 PEACEHEALTH D/B/A KETCHIKAN MEDICAL CENTER
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Covered Entity Details
Entity Name
PEACEHEALTH D/B/A KETCHIKAN MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH021311-00
Entity Address
3100 TONGASS AVE
KETCHIKAN, AK 99901
Medicare Provider Number
021311
Participating Start Date
7/1/2011
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
PEACEHEALTH RIVERBEND OUTPATIENT PHARMAC
Pharmacy Address
PEACEHEALTH RIVERBEND OUTPATIENT PHARMAC
3333 RIVERBEND DR
SPRINGFIELD, OR 97477
Pharmacy Comments
03/06/2014 - Pharmacy name and address correction, changed in error on 3/28/2013, see history for details.
Contract Details
Approval Date
1/5/2012
Contract Begin Date
1/5/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
KEN TONJES, CHIEF FINANCIAL OFFICER
(360) 788-6411
Contract Pharmacy Representative
Greg Ripley, DIRECTOR OF PHARMACY SERVICES
(541) 222-1366
Signed By Date
12/26/2011
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