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COMMCARE PHARMACY-FTL, LLC
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
COMMCARE PHARMACY-FTL, LLC
Pharmacy Address
855 SW 78TH AVE STE C100
PLANTATION, FL 33324-3223
Pharmacy Comments
Contract Details
Approval Date
4/17/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
KEN TONJES, CHIEF FINANCIAL OFFICER
(360) 788-6411
Contract Pharmacy Representative
Kendell McManamy, VP of Operations
(954) 585-7943
Signed By Date
4/17/2015
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