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PREMIER PHARMACY SERVICES
CAH381309-00 LAKE DISTRICT HOSPITAL
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Covered Entity Details
Entity Name
LAKE DISTRICT HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH381309-00
Entity Address
700 SOUTH J ST.
LAKEVIEW, OR 97630
Medicare Provider Number
381309
Participating Start Date
9/28/2010
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
PREMIER PHARMACY SERVICES
Pharmacy Address
410 CLOVERLEAF DR
BALDWIN PARK, CA 91706
Pharmacy Comments
Contract Details
Approval Date
2/1/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/30/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Charles Tveit, Chief Executive Officer
(541) 947-2114 Ext: 221
Contract Pharmacy Representative
Good Health, Inc
Todd Weber, Director, Government Programs & Strategic Initiatives
(203) 212-4717
Signed By Date
2/1/2018
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