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OPTION CARE LEGACY HEALTH, LLC
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
OPTION CARE LEGACY HEALTH, LLC
Pharmacy Address
D/B/A OPTION CARE AT LEGACY HEALTH
2275 NE DOCTORS DR.
SUITE 10
BEND, OR 97701-6324
Pharmacy Comments
Contract Details
Approval Date
4/15/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/1/2018
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
Kristen Johnson, General Manager
(866) 347-8660
Signed By Date
4/15/2016
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