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DAVENPORT PHARMACY INC
CAH501305-00 Lincoln County Public Hospital District No. 3
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Covered Entity Details
Entity Name
Lincoln County Public Hospital District No. 3
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH501305-00
Entity Address
10 Nicholls St
Davenport, WA 99122
Medicare Provider Number
501305
Participating Start Date
7/1/2012
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
DAVENPORT PHARMACY INC
Pharmacy Address
VAN PEVENAGE GERALD L
525 MORGAN, BOX 67
DAVENPORT, WA 99122
Pharmacy Comments
Contract Details
Approval Date
11/28/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tyson Lacy, CEO
(509) 725-2979 Ext: 1168
Contract Pharmacy Representative
Christopher McCowan, Pharmacist
(509) 725-1151
Signed By Date
10/10/2012
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