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FRED MEYER STORES
FQHC638487B Snoqualmie Indian Tribe
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Covered Entity Details
Entity Name
Snoqualmie Indian Tribe
Subdivision Name
North Bend Family Clinic
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638487B
Entity Address
9571 Ethan Wade Way SE
Snoqualmie, WA 98065
Grant Number
Participating Start Date
7/1/2017
Last Recertification Date
3/7/2018
Entity Termination Date
4/1/2019
Pharmacy Details
Pharmacy Name
FRED MEYER STORES
Pharmacy Address
9925 STATE AVENUE
MARYSVILLE, WA 98270
Pharmacy Comments
Contract Details
Approval Date
8/8/2017
Contract Begin Date
8/8/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Virgil Wade, General Manager
(425) 888-6551 Ext: 1234
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
8/8/2017
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