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THRIFTY PAYLESS, INC.
DSH380050 Sky Lakes Medical Center
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Covered Entity Details
Entity Name
Sky Lakes Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380050
Entity Address
2865 Daggett Avenue
Klamath Falls, OR 97601
Medicare Provider Number
380050
Participating Start Date
7/1/2012
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
THRIFTY PAYLESS, INC.
Pharmacy Address
RITE AID #5388
2521 SOUTH SIXTH STREET
KLAMATH FALLS, OR 97601
Pharmacy Comments
Contract Details
Approval Date
10/16/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Richard E. Rico, Vice President/CFO
(541) 274-6150
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
10/16/2015
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