Contract Pharmacy Details

WALGREEN CO.
FQHC638532 Coquille Indian Tribe

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

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS #12901
3411 BROADWAY ST.
NORTH BEND, OR 97459

Pharmacy Comments

Contract Details

Approval Date

7/8/2016

Contract Begin Date

10/1/2016

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Kelle Little, Health and Human Services Administrator
(541) 888-9494 Ext: 2217

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

7/8/2016

340B Drug Pricing Program Database