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WAL-MART PHARMACY 10-5627
CHC24145-00 WALLACE MEDICAL CONCERN, THE
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Covered Entity Details
Entity Name
WALLACE MEDICAL CONCERN, THE
Subdivision Name
Wallace Rockwood Clinic
Type
HRSA-Funded Health Center
340B ID
CHC24145-00
Entity Address
18633 SE Stark St.
Suite 401
Portland, OR 97233-5468
Grant Number
H80CS24145
Participating Start Date
4/1/2014
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5627
Pharmacy Address
3900 W POWELL BLVD
GRESHAM, OR 97030
Pharmacy Comments
Contract Details
Approval Date
7/14/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/15/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lisa Cline, Chief Executive Officer
(503) 907-0591
Contract Pharmacy Representative
Wal-Mart
Marcus Osbourne, Vice President
(800) 939-2022
Signed By Date
7/14/2015
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