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CONFEDERATED TRIBES OF GRAND
FQHC638532 Coquille Indian Tribe
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Covered Entity Details
Entity Name
Coquille Indian Tribe
Subdivision Name
Ko-Kwel Wellness Center
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638532
Entity Address
630 Miluk Drive
Coos Bay, OR 97420
Grant Number
Participating Start Date
7/1/2016
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
CONFEDERATED TRIBES OF GRAND
Pharmacy Address
GRAND RONDE HEALTH & WELLNESS CENTER PHA
9605 GRAND RONDE RD
GRAND RONDE, OR 97347
Pharmacy Comments
Contract Details
Approval Date
6/24/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2016
Contacts
Covered Entity Signing Official
Kelle Little, Health and Human Services Administrator
(541) 888-9494 Ext: 2217
Contract Pharmacy Representative
Julie Davis, Director of Clinical Services
(503) 879-2299
Signed By Date
6/13/2013
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